Provider Demographics
NPI:1780413385
Name:ROMAN, REYNA MARIE
Entity type:Individual
Prefix:
First Name:REYNA
Middle Name:MARIE
Last Name:ROMAN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5045 63RD ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-2546
Mailing Address - Country:US
Mailing Address - Phone:619-439-9143
Mailing Address - Fax:
Practice Address - Street 1:4141 PACIFIC HWY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-2030
Practice Address - Country:US
Practice Address - Phone:619-393-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-31
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMPSS-WSDOEG175T00000X
CA19433101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist