Provider Demographics
NPI:1184022139
Name:REYNOLDS, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7125 CHANNEL DR SE
Mailing Address - Street 2:
Mailing Address - City:ALTO
Mailing Address - State:MI
Mailing Address - Zip Code:49302-9673
Mailing Address - Country:US
Mailing Address - Phone:616-726-5144
Mailing Address - Fax:
Practice Address - Street 1:755 36TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49548-2319
Practice Address - Country:US
Practice Address - Phone:616-726-5144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-08
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical