Provider Demographics
NPI:1003028721
Name:DE LOS REYES, NICHOLAS THOMAS (PHD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:THOMAS
Last Name:DE LOS REYES
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 268
Mailing Address - Street 2:
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85902-0268
Mailing Address - Country:US
Mailing Address - Phone:562-547-0910
Mailing Address - Fax:
Practice Address - Street 1:2051 EVERGREEN LN STE C
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-7928
Practice Address - Country:US
Practice Address - Phone:562-547-0910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY9246103TC0700X
CAMFT13850106H00000X
AZ005077103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist