Provider Demographics
NPI:1609593508
Name:REYNOLDS, ZACHARY ADAM
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:ADAM
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 ANAHEIM ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48111-2940
Mailing Address - Country:US
Mailing Address - Phone:734-845-8522
Mailing Address - Fax:
Practice Address - Street 1:4953 SCHAEFER RD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3260
Practice Address - Country:US
Practice Address - Phone:734-845-8522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-21
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician