Provider Demographics
NPI:1417520511
Name:REYNOLDS, MCKULLY (BCBA)
Entity Type:Individual
Prefix:
First Name:MCKULLY
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3550 PARKWOOD BLVD STE 205
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-1904
Mailing Address - Country:US
Mailing Address - Phone:972-521-9060
Mailing Address - Fax:
Practice Address - Street 1:3550 PARKWOOD BLVD STE 205
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-1904
Practice Address - Country:US
Practice Address - Phone:972-521-9060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-19
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-20-137465106S00000X
TX1-22-62482103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician