Provider Demographics
NPI:1295261667
Name:REYES, JOHNNY ANTHONY
Entity type:Individual
Prefix:
First Name:JOHNNY
Middle Name:ANTHONY
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 1:283 SHILOH RD
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CA
Mailing Address - Zip Code:95492
Mailing Address - Country:US
Mailing Address - Phone:707-393-9976
Mailing Address - Fax:
Practice Address - Street 1:283 SHILOH RD
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CA
Practice Address - Zip Code:95492-9608
Practice Address - Country:US
Practice Address - Phone:707-393-9976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-04
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA91550461F9Medicaid