Provider Demographics
NPI:1821759838
Name:REYNOLDS, RICHARD AXEL (MA, LAMFT)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:AXEL
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:MA, LAMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 W STATE RD STE 102
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-2158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:519 W STATE RD STE 102
Practice Address - Street 2:
Practice Address - City:PLEASANT GROVE
Practice Address - State:UT
Practice Address - Zip Code:84062-2158
Practice Address - Country:US
Practice Address - Phone:385-312-9844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-03
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7132546-3902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT7132546-3902OtherMARRIAGE & FAMILY THERAPIST LICENSE NUMBER