Provider Demographics
NPI:1588852040
Name:REYNOLDS, STEPHANIE REBEKAH (EDS)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:REBEKAH
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1817 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2133
Mailing Address - Country:US
Mailing Address - Phone:602-257-3755
Mailing Address - Fax:
Practice Address - Street 1:1817 N 7TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2133
Practice Address - Country:US
Practice Address - Phone:602-257-3755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-10
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool