Provider Demographics
NPI:1922591254
Name:REYNOLDS, DONALD (LPC CSAC)
Entity Type:Individual
Prefix:MR
First Name:DONALD
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:LPC CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-1919
Mailing Address - Country:US
Mailing Address - Phone:920-728-1810
Mailing Address - Fax:
Practice Address - Street 1:20 SHERMAN AVE E
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-1864
Practice Address - Country:US
Practice Address - Phone:920-728-1810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-12
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6746-125101YM0800X
WI6746125101YP2500X
WI16206-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100078435Medicaid