Provider Demographics
NPI:1730609132
Name:REYNOSO, SANTIAGO JESUS
Entity type:Individual
Prefix:
First Name:SANTIAGO
Middle Name:JESUS
Last Name:REYNOSO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13496 GLADSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:SYLMAR
Mailing Address - State:CA
Mailing Address - Zip Code:91342-2277
Mailing Address - Country:US
Mailing Address - Phone:818-312-6068
Mailing Address - Fax:
Practice Address - Street 1:13496 GLADSTONE AVE
Practice Address - Street 2:
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342-2277
Practice Address - Country:US
Practice Address - Phone:818-312-6068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)