MEDICARE: MITCHELL C. REID LCP

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	0810004560	VA

General Provider Information

NPI Number	:	1710245030
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MITCHELL C. REID LCP

Provider Business Mailing Address
First Line	:	3036 WADDINGTON DR
Second Line	:
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23224-5724
Country	:	US
Telephone Number	:	804-343-7646
Fax Number	:	804-819-5221

Provider Business Practice Location Address
First Line	:	3036 WADDINGTON DR
Second Line	:
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23224-5724
Country	:	US
Telephone Number	:	804-343-7646
Fax Number	:	804-819-5221

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

Provider Enumeration Date	:	04/24/2012
Last Update Date	:	04/24/2012

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