Provider Demographics
NPI:1902052418
Name:REYES, SANTIAGO (CADCII)
Entity Type:Individual
Prefix:MR
First Name:SANTIAGO
Middle Name:
Last Name:REYES
Suffix:
Gender:M
Credentials:CADCII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 E FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-3406
Mailing Address - Country:US
Mailing Address - Phone:626-578-0948
Mailing Address - Fax:
Practice Address - Street 1:2550 E FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-3406
Practice Address - Country:US
Practice Address - Phone:626-578-0948
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-15
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMPSS-IFDRXN175T00000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAICAN822OtherLA COUNTY DMH