Provider Demographics
NPI:1801075304
Name:REYNOLDS, JULIE SLY (MFT)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:SLY
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73700 HIGHWAY 111
Mailing Address - Street 2:SUITE #7
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92260-4019
Mailing Address - Country:US
Mailing Address - Phone:760-625-9092
Mailing Address - Fax:
Practice Address - Street 1:73700 HIGHWAY 111
Practice Address - Street 2:SUITE #7
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-4019
Practice Address - Country:US
Practice Address - Phone:760-625-9092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-31
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49900106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMMM00427MMedicare UPIN