=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477392173
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JULIANNE REYNOLDS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2024
-----------------------------------------------------
Last Update Date | 05/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11628 OLD BALLAS RD
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63141-7030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-368-5745
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11628 OLD BALLAS RD
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63141-7030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-368-5745
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JULIANNE REYNOLDS
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 636-368-5745
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------