Provider Demographics
NPI:1689940488
Name:REYNA, EDDIE (LISW)
Entity Type:Individual
Prefix:
First Name:EDDIE
Middle Name:
Last Name:REYNA
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1932 BENTLEY DR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-4514
Mailing Address - Country:US
Mailing Address - Phone:575-640-8467
Mailing Address - Fax:
Practice Address - Street 1:1932 BENTLEY DR
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-4514
Practice Address - Country:US
Practice Address - Phone:575-640-8467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-26
Last Update Date:2012-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM03-240670-00-31041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical