Provider Demographics
NPI:1932857851
Name:REYNOLDS, JUSTIN MICHAEL
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:MICHAEL
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3971 POINTE N
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30506-5386
Mailing Address - Country:US
Mailing Address - Phone:770-561-3982
Mailing Address - Fax:
Practice Address - Street 1:3971 POINTE N
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30506-5386
Practice Address - Country:US
Practice Address - Phone:770-561-3982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-10
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency