MEDICARE: MR. DAVID ALLEN REYNOLDS LPC, LSW

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	101YP2500X	Professional Counselor	LCP-3385	ID
2	104100000X	Social Worker	LSW-2401	ID

General Provider Information

NPI Number	:	1811139694
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DAVID ALLEN REYNOLDS LPC, LSW

Provider Business Mailing Address
First Line	:	2922 CLEVELAND BLVD STE 500
Second Line	:
City	:	CALDWELL
State	:	ID
Zip	:	83605-6962
Country	:	US
Telephone Number	:	208-453-1439
Fax Number	:	208-453-1443

Provider Business Practice Location Address
First Line	:	2922 CLEVELAND BLVD STE 500
Second Line	:
City	:	CALDWELL
State	:	ID
Zip	:	83605-6962
Country	:	US
Telephone Number	:	208-453-1439
Fax Number	:	208-453-1443

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

Provider Enumeration Date	:	03/25/2009
Last Update Date	:	01/12/2011

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