Provider Demographics
NPI:1871099523
Name:REYNA, ELISSE
Entity type:Individual
Prefix:
First Name:ELISSE
Middle Name:
Last Name:REYNA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELISSE
Other - Middle Name:
Other - Last Name:CABRALES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:501 S WHITE RD
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95127-3258
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2670 S WHITE RD STE 170
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95148-2071
Practice Address - Country:US
Practice Address - Phone:408-755-3905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-02
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA821761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical