Provider Demographics
NPI:1306181748
Name:REYNOLDS, KELLIE RENEE (TLLP)
Entity Type:Individual
Prefix:MRS
First Name:KELLIE
Middle Name:RENEE
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:TLLP
Other - Prefix:MRS
Other - First Name:KELLIE
Other - Middle Name:RENEE
Other - Last Name:EDMONDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:TLLP
Mailing Address - Street 1:5380 HOLIDAY TERRACE
Mailing Address - Street 2:SUITE 32
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009
Mailing Address - Country:US
Mailing Address - Phone:269-459-1512
Mailing Address - Fax:269-459-1514
Practice Address - Street 1:5380 HOLIDAY TERRACE
Practice Address - Street 2:SUITE 32
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009
Practice Address - Country:US
Practice Address - Phone:269-459-1512
Practice Address - Fax:269-459-1514
Is Sole Proprietor?:No
Enumeration Date:2012-12-11
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014983103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist