Healthcare Provider Details

I. General information

NPI: 1376617092
Provider Name (Legal Business Name): ERICA I REYNOSO PH.D. , LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 04/25/2021
Certification Date: 03/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

427 ENCINAL CANYON RD
MALIBU CA
90265-2404
US

IV. Provider business mailing address

PO BOX 10997
MARINA DEL REY CA
90295-6997
US

V. Phone/Fax

Practice location:
  • Phone: 818-735-2805
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS 22233
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number25811
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: