MEDICARE: SANTOSHA MICHELLE REVELS

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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1518219096
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANTOSHA MICHELLE REVELS

Provider Business Mailing Address
First Line	:	5316 SUMMER TROUT ST
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-6616
Country	:	US
Telephone Number	:	702-591-3029
Fax Number	:	702-649-2643

Provider Business Practice Location Address
First Line	:	5316 SUMMER TROUT ST
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-6616
Country	:	US
Telephone Number	:	702-591-3029
Fax Number	:	702-649-2643

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

Provider Enumeration Date	:	10/09/2012
Last Update Date	:	10/09/2012

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