Provider Demographics
NPI:1679063713
Name:REYES, KEISSY MARGARITA
Entity type:Individual
Prefix:
First Name:KEISSY
Middle Name:MARGARITA
Last Name:REYES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 WHITE BIRCH LN
Mailing Address - Street 2:
Mailing Address - City:BLANDON
Mailing Address - State:PA
Mailing Address - Zip Code:19510-9526
Mailing Address - Country:US
Mailing Address - Phone:646-549-2913
Mailing Address - Fax:
Practice Address - Street 1:400 WHITE BIRCH LN
Practice Address - Street 2:
Practice Address - City:BLANDON
Practice Address - State:PA
Practice Address - Zip Code:19510-9526
Practice Address - Country:US
Practice Address - Phone:646-549-2913
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-15
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103459454Medicaid