Provider Demographics
NPI:1750874095
Name:REYNOLDS, ACHANTE JANELLE
Entity type:Individual
Prefix:
First Name:ACHANTE
Middle Name:JANELLE
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 1:563 BALBOA AVE
Mailing Address - Street 2:SUITE 521
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:563 BALBOA AVE
Practice Address - Street 2:SUITE 521
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-12
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician