Basic Information
Provider Information | |||||||||
NPI: | 1972867042 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | REIS | ||||||||
FirstName: | ELIZA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CADC II | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | REIS | ||||||||
OtherFirstName: | ELIZA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CADC II | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 340 RANCHEROS DR | ||||||||
Address2: |   | ||||||||
City: | SAN MARCOS | ||||||||
State: | CA | ||||||||
PostalCode: | 920692900 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7607443672 | ||||||||
FaxNumber: | 9517913353 | ||||||||
Practice Location | |||||||||
Address1: | 340 RANCHEROS DR STE 166 | ||||||||
Address2: |   | ||||||||
City: | SAN MARCOS | ||||||||
State: | CA | ||||||||
PostalCode: | 920692980 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7607443672 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/03/2012 | ||||||||
LastUpdateDate: | 03/05/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/05/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | R1203061415 | CA | Y |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.