Healthcare Provider Details

I. General information

NPI: 1043103500
Provider Name (Legal Business Name): NATHAN A REZA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2025
Last Update Date: 06/02/2025
Certification Date: 06/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4025 CAMINO DEL RIO S STE 329
SAN DIEGO CA
92108-4107
US

IV. Provider business mailing address

4025 CAMINO DEL RIO S STE 329
SAN DIEGO CA
92108-4107
US

V. Phone/Fax

Practice location:
  • Phone: 619-261-9269
  • Fax: 619-618-0688
Mailing address:
  • Phone: 619-261-9269
  • Fax: 619-618-0688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number19320
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: