Healthcare Provider Details

I. General information

NPI: 1336576289
Provider Name (Legal Business Name): KRISTINE AMANDA REZNY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2013
Last Update Date: 01/03/2024
Certification Date: 01/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4425 S JONES BLVD STE D3
LAS VEGAS NV
89103-3370
US

IV. Provider business mailing address

2558 S SEPULVEDA BLVD APT 1
LOS ANGELES CA
90064-3171
US

V. Phone/Fax

Practice location:
  • Phone: 702-991-3150
  • Fax:
Mailing address:
  • Phone: 630-935-8688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberR25050190795
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number115876
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: