Provider Demographics
NPI:1508299215
Name:REYES, LOREN GABRIELA
Entity Type:Individual
Prefix:
First Name:LOREN
Middle Name:GABRIELA
Last Name:REYES
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 1:909 FELLER AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95127-3518
Mailing Address - Country:US
Mailing Address - Phone:408-580-6155
Mailing Address - Fax:
Practice Address - Street 1:2425 ENBORG LN
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-2648
Practice Address - Country:US
Practice Address - Phone:408-885-5403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-16
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
CA114685251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No251S00000XAgenciesCommunity/Behavioral Health