Provider Demographics
NPI:1437624400
Name:REYNOSO HINOJOSA, RAFAEL (LCSW)
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:
Last Name:REYNOSO HINOJOSA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:RAFAEL
Other - Middle Name:
Other - Last Name:REYNOSO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:3628 MEADOW PARK LOOP NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305-1585
Mailing Address - Country:US
Mailing Address - Phone:503-630-3078
Mailing Address - Fax:
Practice Address - Street 1:565 UNION ST NE STE 207
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-2418
Practice Address - Country:US
Practice Address - Phone:503-630-3078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-05
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL76991041C0700X, 101YP2500X, 106H00000X, 1041C0700X
OR101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500757435Medicaid