Healthcare Provider Details

I. General information

NPI: 1366656159
Provider Name (Legal Business Name): KATHLEEN WALSH REYNOLDS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 12/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 POMFRET ST BEHAVIORAL HEALTH - COMMUNITY SVCS BLDG
PUTNAM CT
06260-1836
US

IV. Provider business mailing address

33 POTVIN AVE
MOOSUP CT
06354-1227
US

V. Phone/Fax

Practice location:
  • Phone: 860-963-6385
  • Fax: 860-963-6393
Mailing address:
  • Phone: 203-901-6055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number003150
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: