Provider Demographics
NPI:1114361037
Name:REYNOLDS, RUSS (PHD)
Entity Type:Individual
Prefix:
First Name:RUSS
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 BEAR CREEK RD.
Mailing Address - Street 2:P.O. BOX 2009
Mailing Address - City:OAK RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37831-2820
Mailing Address - Country:US
Mailing Address - Phone:865-574-3434
Mailing Address - Fax:
Practice Address - Street 1:7701 TELEGRAPH RD BLDG 2596
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22315-3822
Practice Address - Country:US
Practice Address - Phone:703-664-5006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-22
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP1422103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical