=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427239862
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RANDAL DAVID REYNOLDS PHD LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2007
-----------------------------------------------------
Last Update Date | 01/02/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4401 WESTOWN PKWY STE 309
-----------------------------------------------------
City | WEST DES MOINES
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50266-6721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-440-3804
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4401 WESTOWN PKWY STE 309
-----------------------------------------------------
City | WEST DES MOINES
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50266-6721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-440-3804
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. RANDAL DAVID REYNOLDS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 515-440-3804
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------