Healthcare Provider Details

I. General information

NPI: 1558492694
Provider Name (Legal Business Name): LORI T REYNOLDS LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 03/02/2024
Certification Date: 03/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12015 BRECKENRIDGE RD
GROVELAND CA
95321-9507
US

IV. Provider business mailing address

12015 BRECKENRIDGE RD
GROVELAND CA
95321-9507
US

V. Phone/Fax

Practice location:
  • Phone: 310-383-4953
  • Fax:
Mailing address:
  • Phone: 310-383-4953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFCC44079
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: