Healthcare Provider Details

I. General information

NPI: 1922591254
Provider Name (Legal Business Name): DONALD REYNOLDS LPC. CSAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2018
Last Update Date: 03/23/2021
Certification Date: 03/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 SHERMAN AVE E
FORT ATKINSON WI
53538-1864
US

IV. Provider business mailing address

615 N 4TH ST
FORT ATKINSON WI
53538-1919
US

V. Phone/Fax

Practice location:
  • Phone: 920-728-1810
  • Fax:
Mailing address:
  • Phone: 920-728-1810
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number16206-132
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6746-125
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6746125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: