Basic Information
| Provider Information | |||||||||
| NPI: | 1700963253 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REYNOLDS | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | H. | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1430 COLLIER ST | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787042911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124457787 | ||||||||
| FaxNumber: | 5124404059 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 W RIVERSIDE DR | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787041247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5128043163 | ||||||||
| FaxNumber: | 5123239544 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 19252 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 84534L | 01 | TX | BCBS (TEXAS) | OTHER |