Provider Demographics
NPI:1326245739
Name:REYNOLDS, DEBBIE
Entity Type:Individual
Prefix:
First Name:DEBBIE
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 1:575 HICKORY AVE
Mailing Address - Street 2:
Mailing Address - City:HARAHAN
Mailing Address - State:LA
Mailing Address - Zip Code:70123-3104
Mailing Address - Country:US
Mailing Address - Phone:504-541-4601
Mailing Address - Fax:
Practice Address - Street 1:800 HICKORY AVE STE D
Practice Address - Street 2:
Practice Address - City:HARAHAN
Practice Address - State:LA
Practice Address - Zip Code:70123-3149
Practice Address - Country:US
Practice Address - Phone:504-541-4601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-29
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 40743106H00000X
LA4765101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA107318OtherSAN JOSE CITY ID #