MEDICARE: ASHLEY REYNVANN

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	101YM0800X	Mental Health Counselor
2	101Y00000X	Counselor	CG60915318	WA

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	:	1235608449
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ASHLEY REYNVANN

Provider Business Mailing Address
First Line	:	PO BOX 2394
Second Line	:
City	:	LONGVIEW
State	:	WA
Zip	:	98632-2315
Country	:	US
Telephone Number	:	360-200-5419
Fax Number	:	360-200-6736

Provider Business Practice Location Address
First Line	:	1616 S. GOLD ST. #4
Second Line	:
City	:	CENTRALIA
State	:	WA
Zip	:	98531-0001
Country	:	US
Telephone Number	:	360-807-4929
Fax Number	:	360-807-4160

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

Provider Enumeration Date	:	11/16/2018
Last Update Date	:	05/04/2021

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Directions to “ ASHLEY REYNVANN ” Practice Location

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