Healthcare Provider Details

I. General information

NPI: 1467232132
Provider Name (Legal Business Name): STEPHANIE JAIMES REZA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2023
Last Update Date: 10/02/2023
Certification Date: 10/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 PINEHURST AVE
SOUTHERN PINES NC
28387-6350
US

IV. Provider business mailing address

945 N CENTRAL AVE
WOODMERE NY
11598-1604
US

V. Phone/Fax

Practice location:
  • Phone: 704-440-3580
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-23-299438
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: