Provider Demographics
NPI:1407319619
Name:REYNOSO, GISELLE JOLIE
Entity Type:Individual
Prefix:
First Name:GISELLE
Middle Name:JOLIE
Last Name:REYNOSO
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 1:205 STERLING RD
Mailing Address - Street 2:
Mailing Address - City:ELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:11003-2032
Mailing Address - Country:US
Mailing Address - Phone:516-499-4822
Mailing Address - Fax:
Practice Address - Street 1:225 BROADHOLLOW RD
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-4822
Practice Address - Country:US
Practice Address - Phone:631-385-7780
Practice Address - Fax:631-385-7795
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-13
Last Update Date:2019-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician