Provider Demographics
NPI:1376687939
Name:REYNOLDS, ROGER M (LCSW)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:M
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 881275
Mailing Address - Street 2:
Mailing Address - City:STEAMBOAT SPGS
Mailing Address - State:CO
Mailing Address - Zip Code:80488
Mailing Address - Country:US
Mailing Address - Phone:970-879-5520
Mailing Address - Fax:970-879-6987
Practice Address - Street 1:1475 PINE GROVE RD.
Practice Address - Street 2:SUITE 206
Practice Address - City:STEAMBOAT SPGS
Practice Address - State:CO
Practice Address - Zip Code:80487
Practice Address - Country:US
Practice Address - Phone:970-879-5520
Practice Address - Fax:970-879-6987
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2008-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9893141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC88506Medicare UPIN