Provider Demographics
NPI:1154779288
Name:REYNOLDS, STEPHANIE MICHELLE (MS)
Entity type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:MICHELLE
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 NW LAKE WHITNEY PL
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-1605
Mailing Address - Country:US
Mailing Address - Phone:772-492-9841
Mailing Address - Fax:
Practice Address - Street 1:525 NW LAKE WHITNEY PL
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1605
Practice Address - Country:US
Practice Address - Phone:772-492-9841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-31
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL900341538Medicaid