Healthcare Provider Details

I. General information

NPI: 1306981006
Provider Name (Legal Business Name): JAMES MARK REYNOLDS PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1519 NYE ROAD WAYNE BEHAVIORAL HEALTH NETWORK
LYONS NY
14489
US

IV. Provider business mailing address

209 LAKE ROAD
ONTARIO NY
14519
US

V. Phone/Fax

Practice location:
  • Phone: 315-946-5722
  • Fax: 315-946-7066
Mailing address:
  • Phone: 585-506-7071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number013321
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: