Provider Demographics
NPI:1750486353
Name:REYNOLDS, SALLY ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:ANN
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:ANN
Other - Last Name:FUNKHOUSER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 10414
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33773-0414
Mailing Address - Country:US
Mailing Address - Phone:800-632-6074
Mailing Address - Fax:
Practice Address - Street 1:520 VALLEY ST
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-7935
Practice Address - Country:US
Practice Address - Phone:800-632-6074
Practice Address - Fax:866-341-7509
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0050571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6106252Medicaid
NC6106252Medicaid