Provider Demographics
NPI:1346816303
Name:REYNOLDS, BROOKE ELIZABETH
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:ELIZABETH
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 1:2671 AVENIR PL APT 1329
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22180-6772
Mailing Address - Country:US
Mailing Address - Phone:703-615-9960
Mailing Address - Fax:
Practice Address - Street 1:5415C BACKLICK RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22151-3915
Practice Address - Country:US
Practice Address - Phone:703-941-1910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-01
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA106S00000X106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1699097139Medicaid