Provider Demographics
NPI:1447557442
Name:REYNOLDS, JOHN BRENTLY II
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:BRENTLY
Last Name:REYNOLDS
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 COTTAGE PARK AVE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02140-1606
Mailing Address - Country:US
Mailing Address - Phone:405-921-2180
Mailing Address - Fax:
Practice Address - Street 1:14 COTTAGE PARK AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02140-1606
Practice Address - Country:US
Practice Address - Phone:405-921-2180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-28
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health