MEDICARE: DIANA REVELES

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	171M00000X	Case Manager/Care Coordinator
2	1041C0700X	Clinical Social Worker	1041C0700X	CA

General Provider Information

NPI Number	:	1295863355
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANA REVELES

Provider Business Mailing Address
First Line	:	920 E SAN ANTONIO DR APT 2
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90807-2220
Country	:	US
Telephone Number	:	916-412-5607
Fax Number	:

Provider Business Practice Location Address
First Line	:	3711 LONG BEACH BLVD STE 500
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90807-3319
Country	:	US
Telephone Number	:	562-216-2179
Fax Number	:

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

Provider Enumeration Date	:	03/01/2007
Last Update Date	:	04/28/2010

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Directions to “ DIANA REVELES ” Practice Location

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