Provider Demographics
NPI:1083768733
Name:REICKS, EDWARD WILLIAM (PH,D,)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:WILLIAM
Last Name:REICKS
Suffix:
Gender:M
Credentials:PH,D,
Other - Prefix:DR
Other - First Name:ED
Other - Middle Name:WILLIAM
Other - Last Name:REICKS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:1440 N HARBOR BLVD
Mailing Address - Street 2:SUITE 127
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-4127
Mailing Address - Country:US
Mailing Address - Phone:714-879-7091
Mailing Address - Fax:714-441-0914
Practice Address - Street 1:1440 N HARBOR BLVD
Practice Address - Street 2:SUITE 127
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-4114
Practice Address - Country:US
Practice Address - Phone:714-879-7091
Practice Address - Fax:714-441-0914
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 11010103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL 11010OtherUSBH
CAPSY 11010OtherSTATE LICENSE
CAPSY11010Medicaid
CACP11010Medicaid
CAPSY 11010OtherSTATE LICENSE
PSY11010Medicare ID - Type Unspecified