MEDICARE: MS. DIANA GLORIA AREVALO M.S. ED.

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	103T00000X	Psychologist

General Provider Information

NPI Number	:	1356794689
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DIANA GLORIA AREVALO M.S. ED.

Provider Business Mailing Address
First Line	:	10818 QUEENS BLVD FL 5
Second Line	:
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-4748
Country	:	US
Telephone Number	:	212-804-7659
Fax Number	:

Provider Business Practice Location Address
First Line	:	10818 QUEENS BLVD FL 5
Second Line	:
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-4748
Country	:	US
Telephone Number	:	212-804-7659
Fax Number	:

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

Provider Enumeration Date	:	07/21/2016
Last Update Date	:	01/28/2019

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