Provider Demographics
NPI:1407242191
Name:REYES, RODNEY SAM (BA, ADV CASAC-G)
Entity type:Individual
Prefix:MR
First Name:RODNEY
Middle Name:SAM
Last Name:REYES
Suffix:
Gender:M
Credentials:BA, ADV CASAC-G
Other - Prefix:MR
Other - First Name:RODNEY
Other - Middle Name:SAM
Other - Last Name:REYES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BA, ADV CASAC-G
Mailing Address - Street 1:770 ST 176
Mailing Address - Street 2:630 CONCORD AVENUE
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10455-1045
Mailing Address - Country:US
Mailing Address - Phone:929-306-7951
Mailing Address - Fax:
Practice Address - Street 1:770 E 176TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10460-4617
Practice Address - Country:US
Practice Address - Phone:929-306-7951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-09
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY28646324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility