Provider Demographics
NPI:1407933120
Name:REYNOLDS, ROBERT BRUCE (LCSW)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:BRUCE
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 MARINE VIEW PLZ
Mailing Address - Street 2:APT. #17F
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-5760
Mailing Address - Country:US
Mailing Address - Phone:201-876-1395
Mailing Address - Fax:
Practice Address - Street 1:750 ASTOR AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-9304
Practice Address - Country:US
Practice Address - Phone:718-882-5000
Practice Address - Fax:718-798-7633
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY072624-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNE5272Medicare ID - Type Unspecified