Provider Demographics
NPI:1619275732
Name:REYNOLDS, KERI DAWN (SSW)
Entity Type:Individual
Prefix:
First Name:KERI
Middle Name:DAWN
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:SSW
Other - Prefix:
Other - First Name:KERI
Other - Middle Name:DAWN
Other - Last Name:GODSEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SSW
Mailing Address - Street 1:750 N 200 W
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-1677
Mailing Address - Country:US
Mailing Address - Phone:801-373-4760
Mailing Address - Fax:
Practice Address - Street 1:750 N 200 W
Practice Address - Street 2:SUITE 300
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-1677
Practice Address - Country:US
Practice Address - Phone:801-373-4760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-14
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7747738-3503104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker