Provider Demographics
NPI:1760512396
Name:REYES, LETICIA J (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:LETICIA
Middle Name:J
Last Name:REYES
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 S 800 W
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-6127
Mailing Address - Country:US
Mailing Address - Phone:208-684-4744
Mailing Address - Fax:
Practice Address - Street 1:495 N SHILLING AVE
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-2336
Practice Address - Country:US
Practice Address - Phone:208-782-2050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW273461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical