MEDICARE: SHANNON LYNNETTE REYNOLDS

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	0704016100	VA

General Provider Information

NPI Number	:	1417639170
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON LYNNETTE REYNOLDS

Provider Business Mailing Address
First Line	:	12519 CAPERNWRAY CT
Second Line	:
City	:	CHESTERFIELD
State	:	VA
Zip	:	23838-5614
Country	:	US
Telephone Number	:	804-536-9187
Fax Number	:

Provider Business Practice Location Address
First Line	:	12519 CAPERNWRAY CT
Second Line	:
City	:	CHESTERFIELD
State	:	VA
Zip	:	23838-5614
Country	:	US
Telephone Number	:	804-216-6040
Fax Number	:

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

Provider Enumeration Date	:	08/02/2023
Last Update Date	:	08/02/2023

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