Provider Demographics
NPI:1124532775
Name:REYNOLDS, GINA L (LLMSW-CLINICAL)
Entity type:Individual
Prefix:MRS
First Name:GINA
Middle Name:L
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:LLMSW-CLINICAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4351 WHEATLAND DR
Mailing Address - Street 2:
Mailing Address - City:SWARTZ CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:48473-8255
Mailing Address - Country:US
Mailing Address - Phone:810-869-9662
Mailing Address - Fax:
Practice Address - Street 1:1121 VILLA LINDE CT
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3410
Practice Address - Country:US
Practice Address - Phone:810-869-9662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-17
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
MI68011019981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker