Provider Demographics
NPI:1114434669
Name:REYNOLDS, NICHOLAS MARTIN (MED, BCBA)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:MARTIN
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4616 25TH AVE NE
Mailing Address - Street 2:PMB 437
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105
Mailing Address - Country:US
Mailing Address - Phone:206-841-0205
Mailing Address - Fax:
Practice Address - Street 1:4616 25TH AVE NE
Practice Address - Street 2:PMB 437
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105
Practice Address - Country:US
Practice Address - Phone:206-841-0205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-05
Last Update Date:2018-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1-17-29063103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst