Basic Information
| Provider Information | |||||||||
| NPI: | 1962860783 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REYNOLDS | ||||||||
| FirstName: | KAYLIE | ||||||||
| MiddleName: | LAUREN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4355 KEMPF ST | ||||||||
| Address2: | |||||||||
| City: | WATERFORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483291801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2487666569 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1225 E BIG BEAVER RD | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480831905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485248801 | ||||||||
| FaxNumber: | 2485248855 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2016 | ||||||||
| LastUpdateDate: | 02/10/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.