Provider Demographics
NPI:1083688188
Name:REYNOLDS, S EUGENE (LCSW)
Entity Type:Individual
Prefix:
First Name:S
Middle Name:EUGENE
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 239
Mailing Address - Street 2:
Mailing Address - City:FISHERSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22939-0239
Mailing Address - Country:US
Mailing Address - Phone:540-932-4629
Mailing Address - Fax:540-932-5875
Practice Address - Street 1:79 N MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:FISHERSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22939-2344
Practice Address - Country:US
Practice Address - Phone:540-213-2525
Practice Address - Fax:540-213-2502
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040018191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008929068Medicaid
VA258368OtherANTHEM
VA2074088OtherCIGNA BEHAVIORAL
VA8929068OtherVA PREMIER
VA083837OtherOPTIMA HEALTH
VA2235184OtherFIRST HEALTH
VA005904A62Medicare ID - Type Unspecified
VA258368OtherANTHEM
VA2074088OtherCIGNA BEHAVIORAL
VAC03262Medicare PIN