Provider Demographics
NPI:1972073104
Name:REYES, KELLY (MA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:REYES
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 W METROPOLITAN DR STE 402
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3504
Mailing Address - Country:US
Mailing Address - Phone:714-954-2900
Mailing Address - Fax:
Practice Address - Street 1:4000 W METROPOLITAN DR STE 402
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3504
Practice Address - Country:US
Practice Address - Phone:714-954-2900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-30
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA109304106H00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty