Provider Demographics
NPI:1710334206
Name:REYNOLDS, ROXANNA (LAC)
Entity Type:Individual
Prefix:
First Name:ROXANNA
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 W MERCURY ST
Mailing Address - Street 2:
Mailing Address - City:BUTTE
Mailing Address - State:MT
Mailing Address - Zip Code:59701-1510
Mailing Address - Country:US
Mailing Address - Phone:406-299-3448
Mailing Address - Fax:406-299-3450
Practice Address - Street 1:630 W MERCURY ST
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-1510
Practice Address - Country:US
Practice Address - Phone:406-299-3448
Practice Address - Fax:406-299-3450
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-16
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTLAC-LAC-LIC-1240101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)