Provider Demographics
NPI:1912620253
Name:REYES, ANGIE IVELISSE (BA)
Entity Type:Individual
Prefix:
First Name:ANGIE
Middle Name:IVELISSE
Last Name:REYES
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:595 W CHURCH ST APT 821
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32805-2299
Mailing Address - Country:US
Mailing Address - Phone:407-683-0510
Mailing Address - Fax:
Practice Address - Street 1:595 W CHURCH ST APT 821
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32805-2299
Practice Address - Country:US
Practice Address - Phone:407-683-0510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-21
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Single Specialty