Provider Demographics
NPI:1417173998
Name:REYES, PAUL ANTHONY
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:ANTHONY
Last Name:REYES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 RISSO CT
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-4938
Mailing Address - Country:US
Mailing Address - Phone:831-475-9069
Mailing Address - Fax:
Practice Address - Street 1:126 FRONT ST # A
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-4402
Practice Address - Country:US
Practice Address - Phone:831-427-9343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA44AVOtherMEDI-CAL PRV NBR