Healthcare Provider Details

I. General information

NPI: 1417530007
Provider Name (Legal Business Name): KAITLIN REYNOLDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2021
Last Update Date: 04/30/2021
Certification Date: 04/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 WINDRIM AVE
PHILADELPHIA PA
19141-2710
US

IV. Provider business mailing address

4206 SARATOGA LN
NORRISTOWN PA
19403-6327
US

V. Phone/Fax

Practice location:
  • Phone: 215-456-2737
  • Fax:
Mailing address:
  • Phone: 302-382-7743
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: