Provider Demographics
NPI:1720473721
Name:REYNOLDS, FAITH
Entity Type:Individual
Prefix:
First Name:FAITH
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13460 WALSH DR
Mailing Address - Street 2:
Mailing Address - City:BOYS TOWN
Mailing Address - State:NE
Mailing Address - Zip Code:68010-7529
Mailing Address - Country:US
Mailing Address - Phone:531-355-3362
Mailing Address - Fax:531-355-3375
Practice Address - Street 1:13460 WALSH DR
Practice Address - Street 2:
Practice Address - City:BOYS TOWN
Practice Address - State:NE
Practice Address - Zip Code:68010-7529
Practice Address - Country:US
Practice Address - Phone:531-355-3362
Practice Address - Fax:531-355-3375
Is Sole Proprietor?:No
Enumeration Date:2015-04-06
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
NE12547101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist