Provider Demographics
NPI:1154923308
Name:REYNOLDS, MATTHEW RUDD
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RUDD
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2929 SW MULTNOMAH BLVD STE 203B
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-4070
Mailing Address - Country:US
Mailing Address - Phone:503-388-7011
Mailing Address - Fax:
Practice Address - Street 1:2929 SW MULTNOMAH BLVD STE 203B
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-4070
Practice Address - Country:US
Practice Address - Phone:503-388-7011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-12
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR5679101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR5679OtherOREGON BOARD OF COUNSELORS AND THERAPISTS