Basic Information
| Provider Information | |||||||||
| NPI: | 1982857991 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REYNOLDS | ||||||||
| FirstName: | WENDIE | ||||||||
| MiddleName: | BRANNEN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | LCSW, ACSW, MA | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 179 PIERCE AVE | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312042821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787421464 | ||||||||
| FaxNumber: | 4787421883 | ||||||||
| Practice Location | |||||||||
| Address1: | 179 PIERCE AVE | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312042821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787421464 | ||||||||
| FaxNumber: | 4787421883 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2008 | ||||||||
| LastUpdateDate: | 02/25/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | CSW002636 | GA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.