Healthcare Provider Details

I. General information

NPI: 1194640458
Provider Name (Legal Business Name): JOHANNES MICHAEL REYNARDUS LCMHCA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2026
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 AVERSBORO RD STE D
GARNER NC
27529-4586
US

IV. Provider business mailing address

1201 AVERSBORO RD STE D
GARNER NC
27529-4586
US

V. Phone/Fax

Practice location:
  • Phone: 786-486-9278
  • Fax:
Mailing address:
  • Phone: 786-486-9278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA23240
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: