Provider Demographics
NPI:1750752572
Name:REYNOLDS, KELLY ELIZABETH (MA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ELIZABETH
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 CIRCLE OF PROGRESS DR
Mailing Address - Street 2:
Mailing Address - City:POTTSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19464-3811
Mailing Address - Country:US
Mailing Address - Phone:610-970-5410
Mailing Address - Fax:
Practice Address - Street 1:5830 SW 89TH PL
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34476-7701
Practice Address - Country:US
Practice Address - Phone:352-598-5652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-20
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
FLMH16556101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)