Provider Demographics
NPI:1942457189
Name:REYNOLDS, WALLACE AVERAL JR (PHD)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:AVERAL
Last Name:REYNOLDS
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 S HIBISCUS DR
Mailing Address - Street 2:
Mailing Address - City:BARTOW
Mailing Address - State:FL
Mailing Address - Zip Code:33830-7242
Mailing Address - Country:US
Mailing Address - Phone:863-398-5996
Mailing Address - Fax:
Practice Address - Street 1:1625 S HIBISCUS DR
Practice Address - Street 2:
Practice Address - City:BARTOW
Practice Address - State:FL
Practice Address - Zip Code:33830-7242
Practice Address - Country:US
Practice Address - Phone:863-398-5996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-19
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPSY-6775103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist