Provider Demographics
NPI:1942207105
Name:REYNOLDS, MAREDA LYNN (MA)
Entity Type:Individual
Prefix:MS
First Name:MAREDA
Middle Name:LYNN
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 904
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:WV
Mailing Address - Zip Code:25177-0904
Mailing Address - Country:US
Mailing Address - Phone:304-727-1302
Mailing Address - Fax:304-727-1302
Practice Address - Street 1:200 KANAWHA TER
Practice Address - Street 2:SUITE 103
Practice Address - City:SAINT ALBANS
Practice Address - State:WV
Practice Address - Zip Code:25177-2867
Practice Address - Country:US
Practice Address - Phone:304-727-1302
Practice Address - Fax:304-727-1302
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV790103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVW41480OtherBLUE CROSS/BLUE SHIELD
WV9204038000Medicaid
WV9204038000Medicaid