Provider Demographics
NPI:1295115095
Name:REEDER, STEPHEN DYLLON
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:DYLLON
Last Name:REEDER
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 1:45550 GRACE ST
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-4610
Mailing Address - Country:US
Mailing Address - Phone:760-342-1233
Mailing Address - Fax:
Practice Address - Street 1:45550 GRACE ST
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-4610
Practice Address - Country:US
Practice Address - Phone:760-342-1233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-05
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA01-124703101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)