Provider Demographics
NPI:1073246443
Name:REYNA, CARLOS NICHOLAS (MT)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:NICHOLAS
Last Name:REYNA
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2603 BRIAR GLENN LN APT 1413
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76006-3433
Mailing Address - Country:US
Mailing Address - Phone:210-683-3324
Mailing Address - Fax:
Practice Address - Street 1:2603 BRIAR GLENN LN APT 1413
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76006-3433
Practice Address - Country:US
Practice Address - Phone:210-683-3324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-05
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT131752225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist