Provider Demographics
NPI:1265042949
Name:REYES, LISSETH (AMFT)
Entity Type:Individual
Prefix:MS
First Name:LISSETH
Middle Name:
Last Name:REYES
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3217 CARSON ST STE 123
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90712-4006
Mailing Address - Country:US
Mailing Address - Phone:949-954-0165
Mailing Address - Fax:
Practice Address - Street 1:1100 QUAIL ST STE 206
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2782
Practice Address - Country:US
Practice Address - Phone:949-954-0165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-06
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT119650106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist