Provider Demographics
NPI:1912377094
Name:REYNOLDS, MICHELLE KATHLEEN (LMFT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:KATHLEEN
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:KATHLEEN
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:165 MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045-3049
Mailing Address - Country:US
Mailing Address - Phone:607-753-0234
Mailing Address - Fax:607-299-4349
Practice Address - Street 1:165 MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045-3049
Practice Address - Country:US
Practice Address - Phone:607-753-0234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-01
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001614106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1336163963Medicaid