Provider Demographics
NPI:1417558792
Name:REYNOLDS, AMY H (LCSW, LADC, CCS)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:H
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:LCSW, LADC, CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 OAK RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:STANDISH
Mailing Address - State:ME
Mailing Address - Zip Code:04084-6019
Mailing Address - Country:US
Mailing Address - Phone:207-756-4455
Mailing Address - Fax:
Practice Address - Street 1:25 MIDDLE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-4869
Practice Address - Country:US
Practice Address - Phone:207-756-4455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC17205106E00000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst