Provider Demographics
NPI:1013420751
Name:REYNOLDS, MANIJEH (LPCC)
Entity Type:Individual
Prefix:
First Name:MANIJEH
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9100 FERN CREEK RD UNIT 91796
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40291-7035
Mailing Address - Country:US
Mailing Address - Phone:316-390-0434
Mailing Address - Fax:502-830-9800
Practice Address - Street 1:7614 PAULS VIEW PL
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40228-1357
Practice Address - Country:US
Practice Address - Phone:316-390-0434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-15
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS03344101YM0800X
KS3056101YP2500X
KY279091101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100837810Medicaid