Provider Demographics
NPI:1508357195
Name:REYNOLDS, AMANDA RAE (LMSW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:RAE
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8037 CORBIN CT
Mailing Address - Street 2:
Mailing Address - City:MOUNT MORRIS
Mailing Address - State:MI
Mailing Address - Zip Code:48458-9370
Mailing Address - Country:US
Mailing Address - Phone:810-730-8074
Mailing Address - Fax:
Practice Address - Street 1:8245 HOLLY RD STE 200
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-2483
Practice Address - Country:US
Practice Address - Phone:810-242-3740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-20
Last Update Date:2023-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
MI101YA0400X
MI6801112229104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)