Provider Demographics
NPI:1669845194
Name:REYES, PRISCILLA
Entity Type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:
Last Name: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 1:4411 E KINGS CANYON RD
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93702-3604
Mailing Address - Country:US
Mailing Address - Phone:559-453-1008
Mailing Address - Fax:
Practice Address - Street 1:4411 E KINGS CANYON RD
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93702-3604
Practice Address - Country:US
Practice Address - Phone:559-453-1008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-05
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
CA95643106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist