Healthcare Provider Details

I. General information

NPI: 1386364743
Provider Name (Legal Business Name): SHAYLIE MACKENZIE REYES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2022
Last Update Date: 09/22/2025
Certification Date: 09/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 N PERRIS BLVD
PERRIS CA
92571-2811
US

IV. Provider business mailing address

555 N PERRIS BLVD
PERRIS CA
92571-2811
US

V. Phone/Fax

Practice location:
  • Phone: 951-436-5366
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberAMFT146624
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: