Provider Demographics
NPI:1144797648
Name:REYNOLDS, MEGAN ROSE
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:ROSE
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:ROSE
Other - Last Name:HAYES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:165 E HAWTHORNE AVE
Mailing Address - Street 2:
Mailing Address - City:COLVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:99114-2629
Mailing Address - Country:US
Mailing Address - Phone:509-684-4597
Mailing Address - Fax:509-684-5286
Practice Address - Street 1:165 E HAWTHORNE AVE
Practice Address - Street 2:
Practice Address - City:COLVILLE
Practice Address - State:WA
Practice Address - Zip Code:99114-2629
Practice Address - Country:US
Practice Address - Phone:509-725-3001
Practice Address - Fax:509-725-1609
Is Sole Proprietor?:No
Enumeration Date:2018-11-01
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60908480101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor