Provider Demographics
NPI:1619089406
Name:REAVIS, JAMES ALTON JR (PSYD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:ALTON
Last Name:REAVIS
Suffix:JR
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:964 FIFTH AVE
Mailing Address - Street 2:#200
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-6102
Mailing Address - Country:US
Mailing Address - Phone:619-234-7970
Mailing Address - Fax:619-699-5945
Practice Address - Street 1:964 FIFTH AVE
Practice Address - Street 2:#200
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-6102
Practice Address - Country:US
Practice Address - Phone:619-234-7970
Practice Address - Fax:619-699-5945
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17404103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
Y11180Medicare UPIN
W17306Medicare ID - Type Unspecified