MEDICARE: MR. ADAM LLOYD REYNOLDS LMSW, CASAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	23622	NY
2	1041C0700X	Clinical Social Worker	082465	NY

General Provider Information

NPI Number	:	1003255050
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ADAM LLOYD REYNOLDS LMSW, CASAC

Provider Business Mailing Address
First Line	:	3727 86TH ST APT 5R
Second Line	:
City	:	JACKSON HTS
State	:	NY
Zip	:	11372-7416
Country	:	US
Telephone Number	:	917-216-0614
Fax Number	:

Provider Business Practice Location Address
First Line	:	3727 86TH ST APT 5R
Second Line	:
City	:	JACKSON HTS
State	:	NY
Zip	:	11372-7416
Country	:	US
Telephone Number	:	917-216-0614
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/21/2013
Last Update Date	:	06/21/2013

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