Provider Demographics
NPI:1700539160
Name:REYES, KEITH BRIAN (LAC, NCC)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:BRIAN
Last Name:REYES
Suffix:
Gender:M
Credentials:LAC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4515 W TYSON ST
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-2902
Mailing Address - Country:US
Mailing Address - Phone:480-262-5005
Mailing Address - Fax:
Practice Address - Street 1:4801 S LAKESHORE DR STE 106
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7156
Practice Address - Country:US
Practice Address - Phone:480-525-0058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-26
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health