Provider Demographics
NPI:1013524628
Name:REYNOLDS, MAC PATRIK (BS PSYCHOLOGY)
Entity Type:Individual
Prefix:MR
First Name:MAC
Middle Name:PATRIK
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:BS PSYCHOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 W PROSSER RD LOT H
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82007-3054
Mailing Address - Country:US
Mailing Address - Phone:307-274-6567
Mailing Address - Fax:
Practice Address - Street 1:620 W PROSSER RD LOT H
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82007-3054
Practice Address - Country:US
Practice Address - Phone:307-274-6567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-28
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY253Z00000X, 251C00000X
372600000X, 373H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No253Z00000XAgenciesIn Home Supportive Care
No372600000XNursing Service Related ProvidersAdult Companion
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist