Provider Demographics
NPI:1255083788
Name:REYNOLDS, MICHAEL (LCSW)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 SUMMIT DR
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-3951
Mailing Address - Country:US
Mailing Address - Phone:203-415-5995
Mailing Address - Fax:
Practice Address - Street 1:25 SUMMIT DR
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-3951
Practice Address - Country:US
Practice Address - Phone:203-415-5995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-26
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT118771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical