Basic Information
| Provider Information | |||||||||
| NPI: | 1497075469 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REYNOLDS | ||||||||
| FirstName: | LORI | ||||||||
| MiddleName: | RENEA | ||||||||
| NamePrefix: | MISS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4550 KEARNY VILLA RD STE 116 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921231583 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8582791223 | ||||||||
| FaxNumber: | 8584677161 | ||||||||
| Practice Location | |||||||||
| Address1: | 31573 RANCHO PUEBLO RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | TEMECULA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925924854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8582791223 | ||||||||
| FaxNumber: | 8584677161 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2010 | ||||||||
| LastUpdateDate: | 11/18/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 106H00000X | 103567 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.