Provider Demographics
NPI:1255008769
Name:REAGERS, MITZI
Entity Type:Individual
Prefix:
First Name:MITZI
Middle Name:
Last Name:REAGERS
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 1:10174 OLD GROVE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92131-1652
Mailing Address - Country:US
Mailing Address - Phone:858-444-8823
Mailing Address - Fax:858-444-8827
Practice Address - Street 1:27555 YNEZ RD STE 406
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-4679
Practice Address - Country:US
Practice Address - Phone:858-444-8823
Practice Address - Fax:858-444-8827
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-24
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1710439559Medicaid