Provider Demographics
NPI:1205205432
Name:REYNOLDS, KATHERINE
Entity Type:Individual
Prefix:
First Name:KATHERINE
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 1:1516 WILLOW LAWN DR
Mailing Address - Street 2:SUITE 203
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23230-3412
Mailing Address - Country:US
Mailing Address - Phone:804-269-4732
Mailing Address - Fax:
Practice Address - Street 1:1516 WILLOW LAWN DR
Practice Address - Street 2:SUITE 203
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-3412
Practice Address - Country:US
Practice Address - Phone:804-269-4732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-17
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110026265EMedicaid