Provider Demographics
NPI:1861721151
Name:REYES, MARTHA JACKELINE
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:JACKELINE
Last Name:REYES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 HOMETOWN AVE
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-8704
Mailing Address - Country:US
Mailing Address - Phone:702-481-1786
Mailing Address - Fax:
Practice Address - Street 1:8100 WESTCLIFF DR
Practice Address - Street 2:MODULAR 8103
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89145-3958
Practice Address - Country:US
Practice Address - Phone:702-673-4745
Practice Address - Fax:702-673-4771
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-15
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVMI0155106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist