Healthcare Provider Details

I. General information

NPI: 1740801455
Provider Name (Legal Business Name): DR. NICOLE REYNOLDS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2020
Last Update Date: 05/04/2020
Certification Date: 05/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

271 3RD ST
ASTORIA OR
97103-4311
US

IV. Provider business mailing address

271 3RD ST
ASTORIA OR
97103-4311
US

V. Phone/Fax

Practice location:
  • Phone: 770-883-3038
  • Fax:
Mailing address:
  • Phone: 770-883-3038
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier500732686
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: DR. NICOLE MARIE REYNOLDS
Title or Position: CLINICAL PSYCHOLOGIST
Credential: PSYD
Phone: 770-883-3038