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General NPI Number Information
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NPI Number | 1376617092
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Entity Type | Individual
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Provider Name | ERICA I REYNOSO PH.D. , LCSW
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Gender | Female
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Dates
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Enumeration Date | 11/17/2006
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Last Update Date | 04/25/2021
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Provider Practice Location Address
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Address Line | 427 ENCINAL CANYON RD
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City | MALIBU
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State | CA
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Zip | 90265-2404
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Country | US
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Telephone | 818-735-2805
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 10997
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City | MARINA DEL REY
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State | CA
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Zip | 90295-6997
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Country | US
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Telephone |
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LCS 22233
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 25811
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License Number State | CA
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