Provider Demographics
NPI:1376606160
Name:MCREYNOLDS, CONNIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:CONNIE
Middle Name:
Last Name:MCREYNOLDS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 ORANGE TREE LN STE 220
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-4582
Mailing Address - Country:US
Mailing Address - Phone:909-435-7189
Mailing Address - Fax:909-922-7580
Practice Address - Street 1:1901 ORANGE TREE LN STE 220
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-4582
Practice Address - Country:US
Practice Address - Phone:909-435-7189
Practice Address - Fax:909-922-7580
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24647103T00000X, 103TC0700X
OH5818103TC1900X, 103TC2200X, 103TF0000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH10034Medicaid
OH10024Medicaid