Provider Demographics
NPI:1417639170
Name:REYNOLDS, SHANNON LYNNETTE
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LYNNETTE
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12519 CAPERNWRAY CT
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23838-5614
Mailing Address - Country:US
Mailing Address - Phone:804-536-9187
Mailing Address - Fax:
Practice Address - Street 1:12519 CAPERNWRAY CT
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23838-5614
Practice Address - Country:US
Practice Address - Phone:804-216-6040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-02
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704016100101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health