Provider Demographics
NPI:1518681758
Name:REAVES, MANTRIEL A
Entity Type:Individual
Prefix:
First Name:MANTRIEL
Middle Name:A
Last Name:REAVES
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 1:5060 N 19TH AVE # 21
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-3210
Mailing Address - Country:US
Mailing Address - Phone:480-853-5514
Mailing Address - Fax:803-753-9196
Practice Address - Street 1:5060 N 19TH AVE # 21
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-3210
Practice Address - Country:US
Practice Address - Phone:480-853-5514
Practice Address - Fax:803-753-9196
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-30
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician