Provider Demographics
NPI:1891239257
Name:REZA, ERNESTO (PSYD)
Entity type:Individual
Prefix:
First Name:ERNESTO
Middle Name:
Last Name:REZA
Suffix:
Gender:
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3137 W INDIAN SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85017-4069
Mailing Address - Country:US
Mailing Address - Phone:775-001-5430
Mailing Address - Fax:415-252-7176
Practice Address - Street 1:3137 W INDIAN SCHOOL RD STE 108
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85017-4069
Practice Address - Country:US
Practice Address - Phone:602-325-5570
Practice Address - Fax:415-252-7176
Is Sole Proprietor?:No
Enumeration Date:2016-12-05
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZPSY-005215103TC0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program