Basic Information
Provider Information | |||||||||
NPI: | 1073847547 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | REYES | ||||||||
FirstName: | INDIRA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MISS | ||||||||
NameSuffix: |   | ||||||||
Credential: | B.A. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 850 N CAMPUS AVE | ||||||||
Address2: | NO. A | ||||||||
City: | UPLAND | ||||||||
State: | CA | ||||||||
PostalCode: | 917863924 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9092890379 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1890 N GAREY AVE | ||||||||
Address2: |   | ||||||||
City: | POMONA | ||||||||
State: | CA | ||||||||
PostalCode: | 917672923 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9096292400 | ||||||||
FaxNumber: | 9096292445 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/30/2009 | ||||||||
LastUpdateDate: | 09/30/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X |   |   | Y |   | Other Service Providers | Case Manager/Care Coordinator |   |
ID Information
ID | Type | State | Issuer | Description | ICAN873 | 01 | CA | LA COUNTY DMH | OTHER |