Provider Demographics
NPI:1518345131
Name:REYNOLDS, TIMOTHY DANIEL (MA)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:DANIEL
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16535 SW TUALATIN VALLEY HWY
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97003-5143
Mailing Address - Country:US
Mailing Address - Phone:503-649-5651
Mailing Address - Fax:503-649-7405
Practice Address - Street 1:16535 SW TUALATIN VALLEY HWY
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97003
Practice Address - Country:US
Practice Address - Phone:503-649-5651
Practice Address - Fax:503-649-7405
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-14
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC3810101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health