Healthcare Provider Details

I. General information

NPI: 1518892934
Provider Name (Legal Business Name): ASHLEY REYNOSO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2026
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24230 KARIM BLVD STE 100
NOVI MI
48375-2960
US

IV. Provider business mailing address

40679 NEWPORT DR
PLYMOUTH MI
48170-4742
US

V. Phone/Fax

Practice location:
  • Phone: 248-745-4900
  • Fax:
Mailing address:
  • Phone: 734-720-2101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number6852094643
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: