Provider Demographics
NPI:1689843658
Name:REYES, GARY M (PHD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:M
Last Name:REYES
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4465 E PARADISE VILLAGE PKWY S APT 1192
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-7767
Mailing Address - Country:US
Mailing Address - Phone:602-578-9704
Mailing Address - Fax:
Practice Address - Street 1:13416 N 32ND ST
Practice Address - Street 2:STE 101C
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-6000
Practice Address - Country:US
Practice Address - Phone:602-578-9704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-25
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3901103TC1900X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling