Provider Demographics
NPI:1124159215
Name:REYNOSO, CARMEN VANESSA
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:VANESSA
Last Name:REYNOSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CARMEN
Other - Middle Name:V
Other - Last Name:REYNOSO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:40 BENNETT AVE
Mailing Address - Street 2:APARTMENT # 4
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90803-2986
Mailing Address - Country:US
Mailing Address - Phone:714-343-8442
Mailing Address - Fax:
Practice Address - Street 1:40 BENNETT AVE
Practice Address - Street 2:APARTMENT # 4
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90803-2986
Practice Address - Country:US
Practice Address - Phone:562-833-8723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF43481225400000X
CAMFC46339106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner