Healthcare Provider Details

I. General information

NPI: 1265552681
Provider Name (Legal Business Name): DIANA MICHELLE REYNOLDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

819 BUSSE HWY MAINE CENTER
PARK RIDGE IL
60068-2360
US

IV. Provider business mailing address

819 BUSSE HWY MAINE CENTER
PARK RIDGE IL
60068-2360
US

V. Phone/Fax

Practice location:
  • Phone: 847-696-1376
  • Fax: 847-696-1587
Mailing address:
  • Phone: 847-696-1376
  • Fax: 847-696-1587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.006464
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: