Basic Information
| Provider Information | |||||||||
| NPI: | 1386149839 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REYNOSO | ||||||||
| FirstName: | BECKY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1315 S GRANT ST | ||||||||
| Address2: | |||||||||
| City: | SAN MATEO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 944021936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6509220908 | ||||||||
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| Practice Location | |||||||||
| Address1: | 957 INDUSTRIAL RD STE B | ||||||||
| Address2: | |||||||||
| City: | SAN CARLOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940704152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6508326900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2018 | ||||||||
| LastUpdateDate: | 09/17/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 172V00000X | CA | Y | Other Service Providers | Community Health Worker |
No ID Information.