Provider Demographics
NPI:1982098000
Name:REYNOSO, EVA (LCSW)
Entity Type:Individual
Prefix:
First Name:EVA
Middle Name:
Last Name:REYNOSO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7627 LAKE STREET
Mailing Address - Street 2:SUITE 206 PMB 1095
Mailing Address - City:RIVER FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7627 LAKE STREET
Practice Address - Street 2:SUITE 206 PMB 1095
Practice Address - City:RIVER FOREST
Practice Address - State:IL
Practice Address - Zip Code:60305
Practice Address - Country:US
Practice Address - Phone:708-513-8452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-26
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
IL1490206641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor