Provider Demographics
NPI:1043711633
Name:REYES, LETICIA (LICMASSAGE THERAPIST)
Entity Type:Individual
Prefix:
First Name:LETICIA
Middle Name:
Last Name:REYES
Suffix:
Gender:F
Credentials:LICMASSAGE THERAPIST
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 118381
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75011-8381
Mailing Address - Country:US
Mailing Address - Phone:469-381-4181
Mailing Address - Fax:
Practice Address - Street 1:4666 MCDERMOTT RD SUITE 100
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75024
Practice Address - Country:US
Practice Address - Phone:972-668-6868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-28
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT102405225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXMT102405OtherLICENSE MASSAGE THERAPY