Basic Information
| Provider Information | |||||||||
| NPI: | 1740400159 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REYNOLDS | ||||||||
| FirstName: | TODD | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MSW, LAT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2526 SEYMOUR AVE | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820013159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076349653 | ||||||||
| FaxNumber: | 3076388256 | ||||||||
| Practice Location | |||||||||
| Address1: | 2526 SEYMOUR AVE | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820013159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076349653 | ||||||||
| FaxNumber: | 3076388256 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2007 | ||||||||
| LastUpdateDate: | 05/21/2015 | ||||||||
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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 | 101YA0400X | PAT-014 | WY | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101Y00000X | 307 | WY | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.