Provider Demographics
NPI:1053452342
Name:MCREYNOLDS, RAE MARIE (L P C)
Entity Type:Individual
Prefix:DR
First Name:RAE
Middle Name:MARIE
Last Name:MCREYNOLDS
Suffix:
Gender:F
Credentials:L P C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 E BRUNDAGE ST
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-6302
Mailing Address - Country:US
Mailing Address - Phone:307-674-9697
Mailing Address - Fax:
Practice Address - Street 1:23 E BRUNDAGE ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-6302
Practice Address - Country:US
Practice Address - Phone:307-674-9697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLPC-607101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYLPC-607OtherLICENSED PROFESSIONAL COU