Provider Demographics
NPI:1962605469
Name:DELOSREYES, RODERICK
Entity type:Individual
Prefix:MR
First Name:RODERICK
Middle Name:
Last Name:DELOSREYES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 W OLYMPIC BLVD STE 600
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015-1475
Mailing Address - Country:US
Mailing Address - Phone:213-553-1884
Mailing Address - Fax:213-236-9662
Practice Address - Street 1:456 ELM AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802-2426
Practice Address - Country:US
Practice Address - Phone:562-437-6717
Practice Address - Fax:562-437-6717
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW 24131101YM0800X
225400000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No171M00000XOther Service ProvidersCase Manager/Care Coordinator