Provider Demographics
NPI:1396459343
Name:REYES, JOSEPH DANIEL (15792-RAC)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:DANIEL
Last Name:REYES
Suffix:
Gender:M
Credentials:15792-RAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 E FRUIT ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-4206
Mailing Address - Country:US
Mailing Address - Phone:949-239-8460
Mailing Address - Fax:
Practice Address - Street 1:11894 ROSECRANS AVE
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650
Practice Address - Country:US
Practice Address - Phone:562-929-7188
Practice Address - Fax:562-929-7575
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-12
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15792-RAC101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)