Provider Demographics
NPI:1740801455
Name:DR. NICOLE REYNOLDS LLC
Entity Type:Organization
Organization Name:DR. NICOLE REYNOLDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:770-883-3038
Mailing Address - Street 1:271 3RD ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-4311
Mailing Address - Country:US
Mailing Address - Phone:770-883-3038
Mailing Address - Fax:
Practice Address - Street 1:271 3RD ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-4311
Practice Address - Country:US
Practice Address - Phone:770-883-3038
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-04
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500732686Medicaid