=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578079166
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREA REYNOLDS MA, LCMHC, LADC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2017
-----------------------------------------------------
Last Update Date | 06/03/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 108 DION ST
-----------------------------------------------------
City | WINOOSKI
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-221-7227
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 108 DION ST
-----------------------------------------------------
City | WINOOSKI
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05404-1517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-221-7227
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 068.0117987
-----------------------------------------------------
License Number State | VT
-----------------------------------------------------