Provider Demographics
NPI:1659471977
Name:REYES, DEBORAH JEANNE PETKOVSEK (PHD)
Entity Type:Individual
Prefix:DR
First Name:DEBORAH
Middle Name:JEANNE PETKOVSEK
Last Name:REYES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2906 BURNEY DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29205-3418
Mailing Address - Country:US
Mailing Address - Phone:803-476-6799
Mailing Address - Fax:
Practice Address - Street 1:4900 BROAD RIVER RD
Practice Address - Street 2:SCDJJ -BWD CAMPUS
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-3531
Practice Address - Country:US
Practice Address - Phone:803-896-9053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1038103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical