Provider Demographics
NPI:1215278775
Name:REYNOLDS, AUDRA (PSYD)
Entity type:Individual
Prefix:
First Name:AUDRA
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7230 HERITAGE VILLAGE PLZ
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GAINESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20155-3053
Mailing Address - Country:US
Mailing Address - Phone:571-921-6721
Mailing Address - Fax:703-754-0311
Practice Address - Street 1:7230 HERITAGE VILLAGE PLZ
Practice Address - Street 2:SUITE 102
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155-3053
Practice Address - Country:US
Practice Address - Phone:571-921-6721
Practice Address - Fax:703-754-0311
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-08
Last Update Date:2013-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810004718103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist