Provider Demographics
NPI:1366675878
Name:REYES, MIRIAM
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:REYES
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 1:8902 WOODMAN AVE
Mailing Address - Street 2:
Mailing Address - City:ARLETA
Mailing Address - State:CA
Mailing Address - Zip Code:91331-6401
Mailing Address - Country:US
Mailing Address - Phone:818-830-7033
Mailing Address - Fax:818-830-7280
Practice Address - Street 1:8902 WOODMAN AVE
Practice Address - Street 2:
Practice Address - City:ARLETA
Practice Address - State:CA
Practice Address - Zip Code:91331-6401
Practice Address - Country:US
Practice Address - Phone:818-830-7033
Practice Address - Fax:818-830-7280
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-31
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC70468FMedicaid