Healthcare Provider Details

I. General information

NPI: 1780413385
Provider Name (Legal Business Name): REYNA MARIE ROMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2024
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2049 SKYLINE DR
LEMON GROVE CA
91945-4221
US

IV. Provider business mailing address

5045 63RD ST
SAN DIEGO CA
92115-2546
US

V. Phone/Fax

Practice location:
  • Phone: 619-465-7303
  • Fax:
Mailing address:
  • Phone: 619-439-9143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-WSDOEG
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number19433
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: