Provider Demographics
NPI:1265418560
Name:REYNOLDS, MICHAEL CONNELL (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:CONNELL
Last Name:REYNOLDS
Suffix:
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 1:251 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27288-3554
Mailing Address - Country:US
Mailing Address - Phone:336-635-1899
Mailing Address - Fax:336-635-1899
Practice Address - Street 1:251 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:NC
Practice Address - Zip Code:27288-3554
Practice Address - Country:US
Practice Address - Phone:336-635-1899
Practice Address - Fax:336-635-1899
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-19
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4211101YP2500X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6102057Medicaid
NC6102058Medicaid