Healthcare Provider Details

I. General information

NPI: 1154076644
Provider Name (Legal Business Name): RUBIT MIROSLABA REYES ROMERO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2022
Last Update Date: 01/04/2024
Certification Date: 01/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44199 MONROE ST
INDIO CA
92201-3096
US

IV. Provider business mailing address

49615 CESAR CHAVEZ ST SPC 106
COACHELLA CA
92236-1430
US

V. Phone/Fax

Practice location:
  • Phone: 760-609-2010
  • Fax:
Mailing address:
  • Phone: 760-609-2010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberMPSS-SKAHRI
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-SKAHRI
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: