Provider Demographics
NPI:1659645737
Name:REYNOLDS, PAULETTE (SST)
Entity Type:Individual
Prefix:
First Name:PAULETTE
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:SST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:585 JEWETT RD
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854-8729
Mailing Address - Country:US
Mailing Address - Phone:517-676-5405
Mailing Address - Fax:517-676-5460
Practice Address - Street 1:4400 S SAGINAW ST
Practice Address - Street 2:SUITE 1460
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-2645
Practice Address - Country:US
Practice Address - Phone:810-237-0799
Practice Address - Fax:810-237-0805
Is Sole Proprietor?:No
Enumeration Date:2012-03-07
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6803064100171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator