MEDICARE: DR. RANDAL DAVID REYNOLDS PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	00993	IA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063431872
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RANDAL DAVID REYNOLDS PH.D.

Provider Business Mailing Address
First Line	:	4401 WESTOWN PKWY
Second Line	:	SUITE 309
City	:	WEST DES MOINES
State	:	IA
Zip	:	50266-6721
Country	:	US
Telephone Number	:	515-440-3801
Fax Number	:	515-440-3701

Provider Business Practice Location Address
First Line	:	4401 WESTOWN PKWY
Second Line	:	SUITE 309
City	:	WEST DES MOINES
State	:	IA
Zip	:	50266-6721
Country	:	US
Telephone Number	:	515-440-3801
Fax Number	:	515-440-3701

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/19/2006
Last Update Date	:	07/08/2007

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