MEDICARE: ARIEL CELESTE SOJOURNER REID

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	PSY.0005327	CO

General Provider Information

NPI Number	:	1982218251
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ARIEL CELESTE SOJOURNER REID

Provider Business Mailing Address
First Line	:	1801 GIBSON BLVD SE APT 1113
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87106-3359
Country	:	US
Telephone Number	:	408-836-3833
Fax Number	:

Provider Business Practice Location Address
First Line	:	2615 E CLINTON AVE
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93703-2223
Country	:	US
Telephone Number	:	408-836-3833
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/03/2020
Last Update Date	:	09/08/2020

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