Healthcare Provider Details

I. General information

NPI: 1235608449
Provider Name (Legal Business Name): ASHLEY REYNVANN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2018
Last Update Date: 05/04/2021
Certification Date: 05/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1616 S. GOLD ST. #4
CENTRALIA WA
98531-0001
US

IV. Provider business mailing address

PO BOX 2394
LONGVIEW WA
98632-2315
US

V. Phone/Fax

Practice location:
  • Phone: 360-807-4929
  • Fax: 360-807-4160
Mailing address:
  • Phone: 360-200-5419
  • Fax: 360-200-6736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCG60915318
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: