Provider Demographics
NPI:1073170080
Name:REYNOLDS, TARA (LPC)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 N MAPLE AVE APT 77
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-1754
Mailing Address - Country:US
Mailing Address - Phone:609-694-3068
Mailing Address - Fax:
Practice Address - Street 1:37 N MAPLE AVE APT 77
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-1754
Practice Address - Country:US
Practice Address - Phone:732-982-2888
Practice Address - Fax:847-859-5885
Is Sole Proprietor?:No
Enumeration Date:2019-05-24
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00401900101YM0800X
NJ37PC00853300101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health