=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275993636
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHELLE M. REYNOLDS, PH.D., LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/29/2016
-----------------------------------------------------
Last Update Date | 02/29/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 33 PRATT ST
-----------------------------------------------------
City | GLASTONBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06033-1014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-376-8284
-----------------------------------------------------
Fax | 860-781-6464
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 165
-----------------------------------------------------
City | DURHAM
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06422-0165
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-376-8284
-----------------------------------------------------
Fax | 860-781-6464
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST
-----------------------------------------------------
Name | DR. MICHELLE M REYNOLDS
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 203-376-8284
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 002786
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------