Basic Information
| Provider Information | |||||||||
| NPI: | 1740576008 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REA | ||||||||
| FirstName: | DENISE | ||||||||
| MiddleName: | MICHELE | ||||||||
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| Credential: | LPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 784 HIGH ST | ||||||||
| Address2: | |||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934015243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055406555 | ||||||||
| FaxNumber: | 8055406501 | ||||||||
| Practice Location | |||||||||
| Address1: | 784 HIGH ST | ||||||||
| Address2: | |||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934015243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055406555 | ||||||||
| FaxNumber: | 8055406501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2011 | ||||||||
| LastUpdateDate: | 06/24/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | PT22692 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.