Provider Demographics
NPI:1093763187
Name:REYNOLDS, BRENT (MSW,LCSW)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:MSW,LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:916 NEVADA HWY
Mailing Address - Street 2:#3
Mailing Address - City:BOULDER CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89005-2300
Mailing Address - Country:US
Mailing Address - Phone:702-294-2866
Mailing Address - Fax:702-294-2866
Practice Address - Street 1:916 NEVADA HWY
Practice Address - Street 2:#3
Practice Address - City:BOULDER CITY
Practice Address - State:NV
Practice Address - Zip Code:89005-2300
Practice Address - Country:US
Practice Address - Phone:702-294-2866
Practice Address - Fax:702-294-2866
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2524-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV37545Medicare ID - Type UnspecifiedPROVIDER ID#