Provider Demographics
NPI:1417486283
Name:REYNOLDS, SUSANNE MICHELLE (ICADCII)
Entity Type:Individual
Prefix:
First Name:SUSANNE
Middle Name:MICHELLE
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:ICADCII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2931 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94518-1025
Mailing Address - Country:US
Mailing Address - Phone:925-676-4840
Mailing Address - Fax:
Practice Address - Street 1:2931 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94518-1025
Practice Address - Country:US
Practice Address - Phone:925-676-4840
Practice Address - Fax:925-676-4840
Is Sole Proprietor?:No
Enumeration Date:2017-06-06
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA324500000XOtherSUBSTANCE ABUSE DISORDER REHABILITATION FACILITY