Provider Demographics
NPI:1548738891
Name:REYES, RICKY REYNALDO II
Entity type:Individual
Prefix:MR
First Name:RICKY
Middle Name:REYNALDO
Last Name:REYES
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4544 SAN FERNANDO RD STE 201
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-5015
Mailing Address - Country:US
Mailing Address - Phone:818-240-8843
Mailing Address - Fax:818-240-8885
Practice Address - Street 1:4544 SAN FERNANDO RD STE 201
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-5015
Practice Address - Country:US
Practice Address - Phone:818-240-8843
Practice Address - Fax:818-240-8885
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-05
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7429101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)