Provider Demographics
NPI:1811049489
Name:REYNOLDS, THERESE (LHMC)
Entity type:Individual
Prefix:MS
First Name:THERESE
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:LHMC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3949 EVANS AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9341
Mailing Address - Country:US
Mailing Address - Phone:941-764-0444
Mailing Address - Fax:941-761-0774
Practice Address - Street 1:3390 TAMIAMI TRL STE 104
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-8161
Practice Address - Country:US
Practice Address - Phone:941-764-0444
Practice Address - Fax:941-761-0774
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH0004312101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health