Provider Demographics
NPI:1922527472
Name:REYNOLDS, MALLICA DAVID
Entity Type:Individual
Prefix:
First Name:MALLICA
Middle Name:DAVID
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3890 W COMMERCIAL BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33309-3346
Mailing Address - Country:US
Mailing Address - Phone:954-644-9567
Mailing Address - Fax:
Practice Address - Street 1:3890 W COMMERCIAL BLVD STE 210
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33309-3346
Practice Address - Country:US
Practice Address - Phone:954-644-9567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-15
Last Update Date:2017-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT3178106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist