Healthcare Provider Details

I. General information

NPI: 1942156369
Provider Name (Legal Business Name): CHARLES NORTON REYNOLDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2026
Last Update Date: 03/09/2026
Certification Date: 03/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 PIXIE TRL
MILL VALLEY CA
94941-3371
US

IV. Provider business mailing address

504 PIXIE TRL
MILL VALLEY CA
94941-3371
US

V. Phone/Fax

Practice location:
  • Phone: 415-710-5315
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberAMFT159603
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: