Provider Demographics
NPI:1982209607
Name:REYES, HERMINIGILDO BORJA
Entity Type:Individual
Prefix:MR
First Name:HERMINIGILDO
Middle Name:BORJA
Last Name:REYES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7475
Mailing Address - Street 2:
Mailing Address - City:KETCHIKAN
Mailing Address - State:AK
Mailing Address - Zip Code:99901-2475
Mailing Address - Country:US
Mailing Address - Phone:907-225-4664
Mailing Address - Fax:907-885-6613
Practice Address - Street 1:2514 FIRST AVE
Practice Address - Street 2:
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-5804
Practice Address - Country:US
Practice Address - Phone:907-225-4664
Practice Address - Fax:907-885-6613
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1021118Medicaid
AK1584706Medicaid