Provider Demographics
NPI:1639696081
Name:REYES, CARLOS EVELIO (DMIN)
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:EVELIO
Last Name:REYES
Suffix:
Gender:M
Credentials:DMIN
Other - Prefix:DR
Other - First Name:CARLOS
Other - Middle Name:E
Other - Last Name:REYES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DR
Mailing Address - Street 1:8631 NW 52ND CT
Mailing Address - Street 2:
Mailing Address - City:LAUDERHILL
Mailing Address - State:FL
Mailing Address - Zip Code:33351-4812
Mailing Address - Country:US
Mailing Address - Phone:1954-649-7863
Mailing Address - Fax:
Practice Address - Street 1:8631 NW 52ND CT
Practice Address - Street 2:
Practice Address - City:LAUDERHILL
Practice Address - State:FL
Practice Address - Zip Code:33351-4812
Practice Address - Country:US
Practice Address - Phone:1954-649-7863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-26
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL31184101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1639696081Medicaid