Provider Demographics
NPI:1922565613
Name:REYES, VIRGINIA RIVAS
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:RIVAS
Last Name:REYES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VIRGINIA
Other - Middle Name:
Other - Last Name:RIVAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 16906
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85011-6906
Mailing Address - Country:US
Mailing Address - Phone:602-279-1427
Mailing Address - Fax:602-279-1431
Practice Address - Street 1:6723 N 61ST AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-3108
Practice Address - Country:US
Practice Address - Phone:623-206-4841
Practice Address - Fax:602-279-1431
Is Sole Proprietor?:No
Enumeration Date:2019-02-28
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9262536104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker