Provider Demographics
NPI:1447744248
Name:REZA, MIRIAM (RBT)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:REZA
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3030 CALLE FRONTERA
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-3009
Mailing Address - Country:US
Mailing Address - Phone:949-272-6146
Mailing Address - Fax:
Practice Address - Street 1:3030 CALLE FRONTERA
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-3009
Practice Address - Country:US
Practice Address - Phone:949-272-6146
Practice Address - Fax:888-847-8864
Is Sole Proprietor?:No
Enumeration Date:2018-06-15
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-18-58356106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician