Provider Demographics
NPI:1669740270
Name:REZA, ANA LILIA
Entity type:Individual
Prefix:
First Name:ANA
Middle Name:LILIA
Last Name:REZA
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 1:11025 THATCHER POND LN
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79934-3113
Mailing Address - Country:US
Mailing Address - Phone:915-820-4163
Mailing Address - Fax:
Practice Address - Street 1:101 MAGUEY CT
Practice Address - Street 2:
Practice Address - City:SUNLAND PARK
Practice Address - State:NM
Practice Address - Zip Code:88063-9513
Practice Address - Country:US
Practice Address - Phone:575-589-2400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-09
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM262026816Medicaid