=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790599579
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAYLEE ROSE REYNOLDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2025
-----------------------------------------------------
Last Update Date | 02/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1108 N MAIN ST
-----------------------------------------------------
City | LOMBARD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60148-1362
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-620-2222
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 901 WARRENVILLE RD STE 500
-----------------------------------------------------
City | LISLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60532-4319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-620-2222
-----------------------------------------------------
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 |
-----------------------------------------------------
License Number State |
-----------------------------------------------------