Provider Demographics
NPI:1760750921
Name:REYNOLDS, GREGORY HOMAN (LICSW, LADC)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:HOMAN
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:LICSW, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:451 LEXINGTON PKWY N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-4636
Mailing Address - Country:US
Mailing Address - Phone:651-280-2310
Mailing Address - Fax:651-280-3995
Practice Address - Street 1:451 LEXINGTON PKWY N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-4636
Practice Address - Country:US
Practice Address - Phone:651-280-2310
Practice Address - Fax:651-280-3995
Is Sole Proprietor?:No
Enumeration Date:2011-12-02
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY24431101YA0400X
MN301886101YA0400X
MN287711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02056453Medicaid