Provider Demographics
NPI:1841605300
Name:REYNOLDS, KIMBERLY DENISE (PHD)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:DENISE
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MRS
Other - First Name:KIMBERLY
Other - Middle Name:DENISE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:POST OFFICE BOX 1096
Mailing Address - Street 2:
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294
Mailing Address - Country:US
Mailing Address - Phone:404-936-0320
Mailing Address - Fax:
Practice Address - Street 1:1078 CITIZEN PARKWAY STE I
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260
Practice Address - Country:US
Practice Address - Phone:404-936-0320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-24
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA101Y00000X, 106H00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator