Provider Demographics
NPI:1790459394
Name:REYNOLDS, DANIELLE MARIE
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:MARIE
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 E ALEXANDRIA AVE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22301-1611
Mailing Address - Country:US
Mailing Address - Phone:802-735-5447
Mailing Address - Fax:
Practice Address - Street 1:1900 MOUNT VERNON AVE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22301-1302
Practice Address - Country:US
Practice Address - Phone:802-735-5447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-06
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
VA09040131021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty