Healthcare Provider Details

I. General information

NPI: 1689843658
Provider Name (Legal Business Name): GARY M. REYES PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2008
Last Update Date: 02/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13416 N 32ND ST STE 101C
PHOENIX AZ
85032-6000
US

IV. Provider business mailing address

4465 E PARADISE VILLAGE PKWY S APT 1192
PHOENIX AZ
85032-7767
US

V. Phone/Fax

Practice location:
  • Phone: 602-578-9704
  • Fax:
Mailing address:
  • Phone: 602-578-9704
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3901
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number3901
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: