Provider Demographics
NPI:1174027262
Name:REYNOSO, JULISSA A (LMHC)
Entity Type:Individual
Prefix:MS
First Name:JULISSA
Middle Name:A
Last Name:REYNOSO
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23483 SW 112TH PL
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-4701
Mailing Address - Country:US
Mailing Address - Phone:305-343-2902
Mailing Address - Fax:
Practice Address - Street 1:DISTRICT 7, BUILDING 6
Practice Address - Street 2:APARTMENT 7
Practice Address - City:CHARENTSAVAN
Practice Address - State:KOTAYK
Practice Address - Zip Code:25021
Practice Address - Country:AM
Practice Address - Phone:305-343-2902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-22
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH14756101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health