Provider Demographics
NPI:1720365570
Name:REYES, SULLY
Entity Type:Individual
Prefix:
First Name:SULLY
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 1:18302 IRVINE BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3437
Mailing Address - Country:US
Mailing Address - Phone:714-881-8664
Mailing Address - Fax:714-957-1065
Practice Address - Street 1:18302 IRVINE BLVD STE 300
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3437
Practice Address - Country:US
Practice Address - Phone:714-881-8664
Practice Address - Fax:714-957-1065
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-08
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst