Provider Demographics
NPI:1669249637
Name:REYES, NELLY J
Entity type:Individual
Prefix:
First Name:NELLY
Middle Name:J
Last Name:REYES
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 1:1436 N WILMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:90744-1912
Mailing Address - Country:US
Mailing Address - Phone:310-684-6859
Mailing Address - Fax:
Practice Address - Street 1:25124 NARBONNE AVE STE 102
Practice Address - Street 2:
Practice Address - City:LOMITA
Practice Address - State:CA
Practice Address - Zip Code:90717-2140
Practice Address - Country:US
Practice Address - Phone:888-286-8715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-08
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty