Provider Demographics
NPI:1215737622
Name:REYNOLDS, NICHOLE BRANDY ANN
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:BRANDY ANN
Last Name:REYNOLDS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:NICHOLE
Other - Middle Name:BRANDY ANN
Other - Last Name:LISTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:661 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-8662
Mailing Address - Country:US
Mailing Address - Phone:719-429-8748
Mailing Address - Fax:
Practice Address - Street 1:701 S 9TH ST
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-4911
Practice Address - Country:US
Practice Address - Phone:719-275-2351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-14
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical