Provider Demographics
NPI:1912958273
Name:REYNA, ALITA GLORIA (PT)
Entity Type:Individual
Prefix:
First Name:ALITA
Middle Name:GLORIA
Last Name:REYNA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 BENVENUE AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-3216
Mailing Address - Country:US
Mailing Address - Phone:973-731-6114
Mailing Address - Fax:
Practice Address - Street 1:554 BLOOMFIELD AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07107-1338
Practice Address - Country:US
Practice Address - Phone:973-483-2277
Practice Address - Fax:973-416-6909
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00987800225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ065587Q97Medicare ID - Type UnspecifiedPHYSICAL THERAPIST