MEDICARE: DR. ELENA REYES PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PY 4094	FL

General Provider Information

NPI Number	:	1285843268
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELENA REYES PHD

Provider Business Mailing Address
First Line	:	PO BOX 2147
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33902-2147
Country	:	US
Telephone Number	:	239-424-1400
Fax Number	:	239-424-1421

Provider Business Practice Location Address
First Line	:	2780 CLEVELAND AVE
Second Line	:	SUITE 709
City	:	FORT MYERS
State	:	FL
Zip	:	33901-5857
Country	:	US
Telephone Number	:	239-343-3831
Fax Number	:	239-343-2301

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/22/2007
Last Update Date	:	11/15/2012

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