Provider Demographics
NPI:1073231759
Name:REYES, WILSON MOISES
Entity Type:Individual
Prefix:
First Name:WILSON
Middle Name:MOISES
Last Name:REYES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2040 46TH TER SW
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34116-5844
Mailing Address - Country:US
Mailing Address - Phone:239-288-1428
Mailing Address - Fax:
Practice Address - Street 1:2040 46TH TER SW
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34116-5844
Practice Address - Country:US
Practice Address - Phone:239-288-1428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-18
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician