Provider Demographics
NPI:1447783352
Name:REYNOLDS, NIETTA
Entity Type:Individual
Prefix:
First Name:NIETTA
Middle Name:
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 1:4935 JUNIUS
Mailing Address - Street 2:9
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75214
Mailing Address - Country:US
Mailing Address - Phone:214-329-6688
Mailing Address - Fax:
Practice Address - Street 1:4935 JUNIUS
Practice Address - Street 2:9
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75214
Practice Address - Country:US
Practice Address - Phone:214-329-6688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-07
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22063991101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health