Provider Demographics
NPI:1518682285
Name:TERCERO DE LOS REYES, FANY KIMBERLY
Entity Type:Individual
Prefix:
First Name:FANY
Middle Name:KIMBERLY
Last Name:TERCERO DE LOS 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 1:1455 S STATE ST SPC 100
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543-7971
Mailing Address - Country:US
Mailing Address - Phone:951-350-2640
Mailing Address - Fax:
Practice Address - Street 1:550 SEAGAZE DR
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-3074
Practice Address - Country:US
Practice Address - Phone:951-350-2640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-05
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-22-236996106S00000X
13861106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician