Provider Demographics
NPI:1962139154
Name:REVELLE, LILIAN A
Entity type:Individual
Prefix:
First Name:LILIAN
Middle Name:A
Last Name:REVELLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1390 EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:MILLBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94030-1411
Mailing Address - Country:US
Mailing Address - Phone:714-881-0427
Mailing Address - Fax:
Practice Address - Street 1:1390 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:MILLBRAE
Practice Address - State:CA
Practice Address - Zip Code:94030-1411
Practice Address - Country:US
Practice Address - Phone:714-881-0427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-06
Last Update Date:2022-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst