Provider Demographics
NPI:1770959850
Name:REYES-RODRIGUEZ, YINA
Entity type:Individual
Prefix:
First Name:YINA
Middle Name:
Last Name:REYES-RODRIGUEZ
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 1:140 E RIDGEWOOD AVE
Mailing Address - Street 2:SUITE 415 OFFICE 456
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652-3915
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:140 E RIDGEWOOD AVE
Practice Address - Street 2:SUITE 415 OFFICE 456
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-3915
Practice Address - Country:US
Practice Address - Phone:718-942-6595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-12
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00617900103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1307576Medicaid
MAM18463OtherBLUE CROSS BLUE SHIELD
MA1303295Medicaid
MAY10086Medicare PIN