Provider Demographics
NPI:1194747170
Name:RESTIVO, GENELL LESLIE (MFT)
Entity type:Individual
Prefix:MRS
First Name:GENELL
Middle Name:LESLIE
Last Name:RESTIVO
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29864 PARADISE HILL LN
Mailing Address - Street 2:
Mailing Address - City:SHINGLETOWN
Mailing Address - State:CA
Mailing Address - Zip Code:96088-9416
Mailing Address - Country:US
Mailing Address - Phone:530-474-3120
Mailing Address - Fax:
Practice Address - Street 1:855 CANYON RD
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-5544
Practice Address - Country:US
Practice Address - Phone:530-378-1855
Practice Address - Fax:530-232-1444
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52551106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist