Provider Demographics
NPI:1790110500
Name:REZA, MONICA OLGA
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:OLGA
Last Name:REZA
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 1:9600 VETERANS DR SW # A-122SW
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98493-5933
Mailing Address - Country:US
Mailing Address - Phone:253-241-9830
Mailing Address - Fax:253-589-4035
Practice Address - Street 1:9600 VETERANS DR SW # A-122SW
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98493-3205
Practice Address - Country:US
Practice Address - Phone:909-986-7111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-11
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD6509978104100000X
WALW609479291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker