Provider Demographics
NPI:1356191001
Name:REYNOSO, QUINN ALEXANDRIA
Entity type:Individual
Prefix:
First Name:QUINN
Middle Name:ALEXANDRIA
Last Name:REYNOSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1238 S WOODS AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90022-5002
Mailing Address - Country:US
Mailing Address - Phone:626-784-8521
Mailing Address - Fax:
Practice Address - Street 1:2115 W CRESCENT AVE STE 244
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-3836
Practice Address - Country:US
Practice Address - Phone:714-829-4138
Practice Address - Fax:714-860-4164
Is Sole Proprietor?:No
Enumeration Date:2024-03-25
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician