Provider Demographics
NPI:1275683435
Name:REYNA, MARISOL
Entity Type:Individual
Prefix:
First Name:MARISOL
Middle Name:
Last Name:REYNA
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 1:5479 EL CAMILE AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94619-3210
Mailing Address - Country:US
Mailing Address - Phone:510-534-1531
Mailing Address - Fax:
Practice Address - Street 1:205 39TH ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94805-2212
Practice Address - Country:US
Practice Address - Phone:510-412-5930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health