Provider Demographics
NPI:1043735731
Name:REYNOLDS, VIRGINIA (LCPC 180 007 760)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:LCPC 180 007 760
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11413 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-4119
Mailing Address - Country:US
Mailing Address - Phone:773-991-5224
Mailing Address - Fax:
Practice Address - Street 1:11413 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-4119
Practice Address - Country:US
Practice Address - Phone:773-991-5224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-007-760101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180-007-760OtherSTATE OF ILLINOIS