Provider Demographics
NPI:1114119591
Name:REYES, DARA (PSYD)
Entity Type:Individual
Prefix:MS
First Name:DARA
Middle Name:
Last Name:REYES
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6160 MISSION GORGE RD STE 108
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-3425
Mailing Address - Country:US
Mailing Address - Phone:619-481-5200
Mailing Address - Fax:
Practice Address - Street 1:6160 MISSION GORGE RD STE 108
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-3425
Practice Address - Country:US
Practice Address - Phone:619-481-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2015-06-18
Deactivation Date:2009-12-17
Deactivation Code:
Reactivation Date:2010-02-11
Provider Licenses
StateLicense IDTaxonomies
CAPSY 27297103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical