Provider Demographics
NPI:1952893752
Name:REYES, LOURDES
Entity type:Individual
Prefix:
First Name:LOURDES
Middle Name:
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 1:800 S ELDORADO ROAD
Mailing Address - Street 2:STE 300
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704
Mailing Address - Country:US
Mailing Address - Phone:331-529-6833
Mailing Address - Fax:315-296-8333
Practice Address - Street 1:5353 N UNION BLVD STE 202
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-2069
Practice Address - Country:US
Practice Address - Phone:970-310-3406
Practice Address - Fax:888-965-4615
Is Sole Proprietor?:No
Enumeration Date:2018-06-06
Last Update Date:2024-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490272481041C0700X
COCSW.099307911041C0700X
IL150104570104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker