Provider Demographics
NPI:1003203944
Name:REYNOSO, MARTA ELENA (LCSW)
Entity Type:Individual
Prefix:
First Name:MARTA
Middle Name:ELENA
Last Name:REYNOSO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:954 HELEN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-2128
Mailing Address - Country:US
Mailing Address - Phone:510-499-8944
Mailing Address - Fax:
Practice Address - Street 1:409 JACKSON ST
Practice Address - Street 2:SUITE 200
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94544-1530
Practice Address - Country:US
Practice Address - Phone:510-891-5650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-17
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA283941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical