Provider Demographics
NPI:1114737335
Name:REYNOLDS, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 W LAIR ST
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62892-1200
Mailing Address - Country:US
Mailing Address - Phone:618-292-9098
Mailing Address - Fax:
Practice Address - Street 1:4110 N WATER TOWER PL
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6295
Practice Address - Country:US
Practice Address - Phone:618-242-2066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-09
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health