Provider Demographics
NPI:1255768594
Name:DELOS REYES, LORA (MA, LMFT)
Entity type:Individual
Prefix:
First Name:LORA
Middle Name:
Last Name:DELOS REYES
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17821 17TH ST STE 290
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-2171
Mailing Address - Country:US
Mailing Address - Phone:714-406-0502
Mailing Address - Fax:
Practice Address - Street 1:17821 17TH ST STE 290
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-2171
Practice Address - Country:US
Practice Address - Phone:714-406-0502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-01
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF84834101YM0800X, 106H00000X
CAPCCI1860101YP2500X
171M00000X, 390200000X
CA111170106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program