Provider Demographics
NPI:1629229158
Name:REYNERSON, KELLY M (LMSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:REYNERSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1929 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-3108
Mailing Address - Country:US
Mailing Address - Phone:601-482-7377
Mailing Address - Fax:601-482-7332
Practice Address - Street 1:1929 23RD AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-3108
Practice Address - Country:US
Practice Address - Phone:601-482-7377
Practice Address - Fax:601-482-7332
Is Sole Proprietor?:No
Enumeration Date:2008-10-02
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA97961041S0200X
MSM76951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool