Healthcare Provider Details

I. General information

NPI: 1790366797
Provider Name (Legal Business Name): MICHELLE BERNADETTE REYES LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2021
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 WEST D.L. INGRAM AVE., BLDG. 1408
CANNON AIR FORCE BASE NM
88103-5014
US

IV. Provider business mailing address

224 WEST D.L. INGRAM AVE., BLDG. 1408
CANNON AIR FORCE BASE NM
88103-5014
US

V. Phone/Fax

Practice location:
  • Phone: 505-784-2778
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number65726
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number20789
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: