Provider Demographics
NPI:1457474843
Name:REYNOLDS, RANDALL T (MED)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:T
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 N. 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85705-7801
Mailing Address - Country:US
Mailing Address - Phone:560-622-1482
Mailing Address - Fax:520-623-7073
Practice Address - Street 1:631 N 2ND AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85705-7801
Practice Address - Country:US
Practice Address - Phone:520-622-1482
Practice Address - Fax:520-623-7073
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-0523101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional