Healthcare Provider Details

I. General information

NPI: 1144227844
Provider Name (Legal Business Name): JOHN MARTIN REYNOLDS MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 04/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 S MELDRUM ST
FT COLLINS CO
80521-2071
US

IV. Provider business mailing address

205 S MELDRUM ST PO BOX 343
FT COLLINS CO
80521-2071
US

V. Phone/Fax

Practice location:
  • Phone: 970-484-3494
  • Fax:
Mailing address:
  • Phone: 970-484-3494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number989313
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number083
License Number StateWY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier304151
Identifier TypeOTHER
Identifier StateWY
Identifier IssuerBLUE SHIELD NUMBER

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: