MEDICARE: ANDREA GUADALUPE REYES SOLORIO

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	106S00000X	Behavior Technician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0123	OTHER		N/A

General Provider Information

NPI Number	:	1508405531
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA GUADALUPE REYES SOLORIO

Provider Business Mailing Address
First Line	:	2233 84TH AVE APT B
Second Line	:
City	:	OAKLAND
State	:	CA
Zip	:	94605-3490
Country	:	US
Telephone Number	:	510-878-0954
Fax Number	:

Provider Business Practice Location Address
First Line	:	2233 84TH AVE APT B
Second Line	:
City	:	OAKLAND
State	:	CA
Zip	:	94605-3490
Country	:	US
Telephone Number	:	510-878-0954
Fax Number	:

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

Provider Enumeration Date	:	12/20/2019
Last Update Date	:	12/20/2019

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