Healthcare Provider Details

I. General information

NPI: 1306181748
Provider Name (Legal Business Name): KELLIE RENEE REYNOLDS LP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLIE RENEE EDMONDS TLLP

II. Dates (important events)

Enumeration Date: 12/11/2012
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 S LOUISIANA ST STE 224
KENNEWICK WA
99336-9003
US

IV. Provider business mailing address

30 S LOUISIANA ST STE 224
KENNEWICK WA
99336-9003
US

V. Phone/Fax

Practice location:
  • Phone: 509-392-1190
  • Fax: 509-769-0933
Mailing address:
  • Phone: 509-392-1190
  • Fax: 509-769-0933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSYC.PY.60706359
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: