Provider Demographics
NPI:1083348106
Name:REYES, GISSELLE B
Entity Type:Individual
Prefix:
First Name:GISSELLE
Middle Name:B
Last Name:REYES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3705 PALMERSTON RD
Mailing Address - Street 2:
Mailing Address - City:SHAKER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5092
Mailing Address - Country:US
Mailing Address - Phone:401-474-9208
Mailing Address - Fax:
Practice Address - Street 1:25 CHRISTY DR
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-1813
Practice Address - Country:US
Practice Address - Phone:508-586-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-14
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health