Healthcare Provider Details

I. General information

NPI: 1215720438
Provider Name (Legal Business Name): ANASTASIA PEARL REYES PT, DPT, CSCS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2025
Last Update Date: 05/28/2025
Certification Date: 05/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2619 W FAIRVIEW AVE
BOISE ID
83702-6722
US

IV. Provider business mailing address

225 S LINDER RD APT O201
EAGLE ID
83616-4495
US

V. Phone/Fax

Practice location:
  • Phone: 208-706-2676
  • Fax:
Mailing address:
  • Phone: 602-615-7940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number9171465
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: