Provider Demographics
NPI:1073847547
Name:REYES, INDIRA (BA)
Entity Type:Individual
Prefix:MISS
First Name:INDIRA
Middle Name:
Last Name:REYES
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 N CAMPUS AVE
Mailing Address - Street 2:NO. A
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-3924
Mailing Address - Country:US
Mailing Address - Phone:909-289-0379
Mailing Address - Fax:
Practice Address - Street 1:1890 N GAREY AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-2923
Practice Address - Country:US
Practice Address - Phone:909-629-2400
Practice Address - Fax:909-629-2445
Is Sole Proprietor?:No
Enumeration Date:2009-09-30
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAICAN873OtherLA COUNTY DMH