Provider Demographics
NPI:1881376978
Name:REYES, ANNETTE ELIZABETH
Entity type:Individual
Prefix:MS
First Name:ANNETTE
Middle Name:ELIZABETH
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 1:2211 E PALMDALE BLVD STE I
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93550-4949
Mailing Address - Country:US
Mailing Address - Phone:909-599-1227
Mailing Address - Fax:
Practice Address - Street 1:2211 E PALMDALE BLVD STE I
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93550-4949
Practice Address - Country:US
Practice Address - Phone:909-599-1227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-07
Last Update Date:2024-09-13
Deactivation Date:2023-12-01
Deactivation Code:
Reactivation Date:2024-01-10
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 171M00000X
CAASW125387104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator