Provider Demographics
NPI:1821476664
Name:REYES, ELIZABETH (PHD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:REYES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10801 NATIONAL BLVD STE 253
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-4178
Mailing Address - Country:US
Mailing Address - Phone:310-889-8215
Mailing Address - Fax:
Practice Address - Street 1:10801 NATIONAL BLVD STE 253
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-4178
Practice Address - Country:US
Practice Address - Phone:310-889-8215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-13
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20655103TC0700X, 103TC1900X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1922283233OtherNPI ORGANIZATION TYPE 2 FOR MY SOLE PROPRIETOR (I HAVE TYPE 2 INSTEAD OF 1)