Healthcare Provider Details

I. General information

NPI: 1871362558
Provider Name (Legal Business Name): RENEE REYNOLDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2023
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1777 AXTELL DR STE 100
TROY MI
48084-4400
US

IV. Provider business mailing address

1777 AXTELL DR STE 100
TROY MI
48084-4400
US

V. Phone/Fax

Practice location:
  • Phone: 248-973-4060
  • Fax: 248-385-1193
Mailing address:
  • Phone: 248-973-4060
  • Fax: 248-385-1193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6362010203
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: