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General NPI Number Information
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NPI Number | 1003028721
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Entity Type | Individual
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Provider Name | NICHOLAS THOMAS DE LOS REYES PH.D.
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Gender | Male
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Dates
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Enumeration Date | 05/04/2007
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Last Update Date | 10/26/2021
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Provider Practice Location Address
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Address Line | 2051 EVERGREEN LN STE C
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City | SHOW LOW
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State | AZ
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Zip | 85901-7928
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Country | US
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Telephone | 562-547-0910
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 268
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City | SHOW LOW
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State | AZ
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Zip | 85902-0268
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Country | US
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Telephone | 562-547-0910
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY9246
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | MFT13850
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 005077
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License Number State | AZ
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