Provider Demographics
NPI:1619998010
Name:RAYNOLDS, DAVID AF (MA, LPC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:AF
Last Name:RAYNOLDS
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:NANDO
Other - Middle Name:
Other - Last Name:RAYNOLDS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA, LPC
Mailing Address - Street 1:PO BOX 503010
Mailing Address - Street 2:
Mailing Address - City:WHITE CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97503-0813
Mailing Address - Country:US
Mailing Address - Phone:541-941-7792
Mailing Address - Fax:503-419-4662
Practice Address - Street 1:600 SISKIYOU BLVD
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-2140
Practice Address - Country:US
Practice Address - Phone:541-821-6623
Practice Address - Fax:541-535-1778
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC0943103T00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103T00000XBehavioral Health & Social Service ProvidersPsychologist