Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TR0400X | Rehabilitation Psychologist | B5019841 | CA |
NPI | 1508230541 |
---|---|
Provider Name | David Reynoso |
First Address | Montclair, CA 91763-3865 |
Second Address | Montclair, CA 91763-3865 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/11/2015 |
Last Update Date | 13/11/2015 |