Provider Demographics
NPI:1396219820
Name:REYES, MARYELLEN GERONIMO (LCSW-R)
Entity Type:Individual
Prefix:
First Name:MARYELLEN
Middle Name:GERONIMO
Last Name:REYES
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 WALTERS AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-4121
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2285 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-6631
Practice Address - Country:US
Practice Address - Phone:646-409-7687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-17
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0517671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical