Provider Demographics
NPI:1518422377
Name:REYNOLDS, MARIE
Entity Type:Individual
Prefix:
First Name:MARIE
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 1:7107 S YALE AVE # 161
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-6308
Mailing Address - Country:US
Mailing Address - Phone:405-310-5306
Mailing Address - Fax:405-310-4934
Practice Address - Street 1:1018 24TH AVE NW STE 110
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-6556
Practice Address - Country:US
Practice Address - Phone:405-310-5306
Practice Address - Fax:405-310-4934
Is Sole Proprietor?:No
Enumeration Date:2019-02-06
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247200000X
OKRBT-19-77394106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other