Provider Demographics
NPI:1649580077
Name:REYNOLDS, SHANNON (MA, LPCC)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:MA, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 67523
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87193-7523
Mailing Address - Country:US
Mailing Address - Phone:505-350-2873
Mailing Address - Fax:
Practice Address - Street 1:5800 NORTHVIEW LN NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-2038
Practice Address - Country:US
Practice Address - Phone:505-350-2873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-19
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0096931101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health