MEDICARE: SIVAN REVIVO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	27586	CA

General Provider Information

NPI Number	:	1235776071
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SIVAN REVIVO

Provider Business Mailing Address
First Line	:	6300 BEEMAN AVE
Second Line	:
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91606-3123
Country	:	US
Telephone Number	:	818-572-7275
Fax Number	:

Provider Business Practice Location Address
First Line	:	19730 VENTURA BLVD STE 103B
Second Line	:
City	:	WOODLAND HILLS
State	:	CA
Zip	:	91364-2693
Country	:	US
Telephone Number	:	818-884-5103
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/27/2019
Last Update Date	:	11/27/2019

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Directions to “ SIVAN REVIVO ” Practice Location

Language	Start Address	Practice Location

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