Provider Demographics
NPI:1275076937
Name:REYNOLDS, NICHOLAS JON
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JON
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1480 LINCOLN AVE STE 8
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-2085
Mailing Address - Country:US
Mailing Address - Phone:415-456-7724
Mailing Address - Fax:
Practice Address - Street 1:11100 SAN PABLO AVE
Practice Address - Street 2:
Practice Address - City:EL CERRITO
Practice Address - State:CA
Practice Address - Zip Code:94530-2194
Practice Address - Country:US
Practice Address - Phone:510-525-6225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-29
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health