Provider Demographics
NPI:1093327439
Name:REYES VAZQUEZ, AXEL DAVID
Entity Type:Individual
Prefix:
First Name:AXEL
Middle Name:DAVID
Last Name:REYES VAZQUEZ
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:IDAMARIS GARDENS CALLE JUAN M MORALES L-19
Mailing Address - Street 2:
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00727
Mailing Address - Country:US
Mailing Address - Phone:787-374-8390
Mailing Address - Fax:
Practice Address - Street 1:CALLE JUAN PENA REYES #977
Practice Address - Street 2:CONDOMINIO SABANA VILLAGE
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00924
Practice Address - Country:US
Practice Address - Phone:787-294-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-18
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR7598103TC0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program