Provider Demographics
NPI:1417372665
Name:REYES, PETER GLEN
Entity Type:Individual
Prefix:
First Name:PETER GLEN
Middle Name:
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 1:433 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11217-1702
Mailing Address - Country:US
Mailing Address - Phone:718-998-3020
Mailing Address - Fax:718-998-9059
Practice Address - Street 1:2634 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-4516
Practice Address - Country:US
Practice Address - Phone:718-769-7878
Practice Address - Fax:718-769-7879
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-25
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY8466216225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant