MEDICARE: RUSS REYNOLDS PH.D.

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	103TC0700X	Clinical Psychologist	P1422	TN

General Provider Information

NPI Number	:	1114361037
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUSS REYNOLDS PH.D.

Provider Business Mailing Address
First Line	:	301 BEAR CREEK RD.
Second Line	:	P.O. BOX 2009
City	:	OAK RIDGE
State	:	TN
Zip	:	37831-2820
Country	:	US
Telephone Number	:	865-574-3434
Fax Number	:

Provider Business Practice Location Address
First Line	:	7701 TELEGRAPH RD BLDG 2596
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22315-3822
Country	:	US
Telephone Number	:	703-664-5006
Fax Number	:

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

Provider Enumeration Date	:	04/22/2013
Last Update Date	:	04/22/2022

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Directions to “ RUSS REYNOLDS PH.D.” Practice Location

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