Provider Demographics
NPI:1972984102
Name:REYNOSO, MARISOL (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:MARISOL
Middle Name:
Last Name:REYNOSO
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2311 S MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93292-1370
Mailing Address - Country:US
Mailing Address - Phone:559-901-0181
Mailing Address - Fax:
Practice Address - Street 1:1502 I ST
Practice Address - Street 2:
Practice Address - City:REEDLEY
Practice Address - State:CA
Practice Address - Zip Code:93654-3350
Practice Address - Country:US
Practice Address - Phone:559-305-7130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-12
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-14-10279103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst