Provider Demographics
NPI:1558109454
Name:REYES, IVETTE ALEJANDRA
Entity type:Individual
Prefix:
First Name:IVETTE
Middle Name:ALEJANDRA
Last Name:REYES
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9808 VENICE BLVD STE 505
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-6818
Mailing Address - Country:US
Mailing Address - Phone:310-945-3350
Mailing Address - Fax:
Practice Address - Street 1:9808 VENICE BLVD STE 505
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-6818
Practice Address - Country:US
Practice Address - Phone:310-945-3350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-16
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA152508106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program