Doctor Name: | DR. REVA LEE HERON |
NPI Number: | 1184794315 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | PHD |
License Number: | 0780 |
Business Practice Address: | 190 Central Park Sq Suite 109, Box 10900 Los Alamos, NM - 875444001 |
Business Phone Number: | 5054902381 |
Business Fax Number: | |
Mailing Address: | 190 Central Park Sq, Suite 109, Box 10900 LOS ALAMOS |
State: | NM |
Postal Code: | 875444001 |
Phone Number: | 5054902381 |
Fax Number: | |
NPI Enumeration Date: | 11/08/2006 |
NPI Last Update Date: | 07/08/2007 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 103TC0700X |
License Number: | 0780 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | NM |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Psychologist |
Taxonomy Specialization: | Clinical |
Taxonomy Definition: |