Provider Demographics
NPI:1962090761
Name:REVERVALE PSYCHOTHERAPY PC
Entity type:Organization
Organization Name:REVERVALE PSYCHOTHERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VINH
Authorized Official - Middle Name:Q
Authorized Official - Last Name:THAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-714-7595
Mailing Address - Street 1:1636 WATSON CT
Mailing Address - Street 2:
Mailing Address - City:MILPITAS
Mailing Address - State:CA
Mailing Address - Zip Code:95035-6822
Mailing Address - Country:US
Mailing Address - Phone:650-714-7595
Mailing Address - Fax:669-235-8105
Practice Address - Street 1:1636 WATSON CT
Practice Address - Street 2:
Practice Address - City:MILPITAS
Practice Address - State:CA
Practice Address - Zip Code:95035-6822
Practice Address - Country:US
Practice Address - Phone:650-714-7595
Practice Address - Fax:669-235-8105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-06
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center