Healthcare Provider Details

I. General information

NPI: 1083791735
Provider Name (Legal Business Name): KRISTIN KORAB REYNOLDS LCSW, LCADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 09/19/2023
Certification Date: 09/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 CLAREMONT AVE FL 2
MONTCLAIR NJ
07042-2813
US

IV. Provider business mailing address

PO BOX 656
ESSEX FELLS NJ
07021-0656
US

V. Phone/Fax

Practice location:
  • Phone: 201-591-5371
  • Fax:
Mailing address:
  • Phone: 201-591-5371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC05302900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: