Provider Demographics
NPI:1386307726
Name:ELIAS, REYNALDO JR (INTERN)
Entity type:Individual
Prefix:
First Name:REYNALDO
Middle Name:
Last Name:ELIAS
Suffix:JR
Gender:M
Credentials:INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 E HILLSIDE RD
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78041-3318
Mailing Address - Country:US
Mailing Address - Phone:956-728-0440
Mailing Address - Fax:
Practice Address - Street 1:1205 E HILLSIDE RD
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041-3318
Practice Address - Country:US
Practice Address - Phone:956-728-0440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-21
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX56786101YA0400X
TX101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)