Provider Demographics
NPI:1972116689
Name:REYES, LARA (SLP)
Entity type:Individual
Prefix:MS
First Name:LARA
Middle Name:
Last Name:REYES
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 SOUTHAMPTON RD APT 139
Mailing Address - Street 2:
Mailing Address - City:BENICIA
Mailing Address - State:CA
Mailing Address - Zip Code:94510-1743
Mailing Address - Country:US
Mailing Address - Phone:707-400-7864
Mailing Address - Fax:
Practice Address - Street 1:612 DEL MAR AVE
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-2605
Practice Address - Country:US
Practice Address - Phone:707-556-8420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-24
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15934235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist