Provider Demographics
NPI:1275340093
Name:REYNOLDS, ANDY
Entity type:Individual
Prefix:
First Name:ANDY
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:FRED
Other - Middle Name:ANDREW
Other - Last Name:REYNOLDS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:COUNSELOR 2 C
Mailing Address - Street 1:4366 FLOYD HWY N
Mailing Address - Street 2:
Mailing Address - City:FLOYD
Mailing Address - State:VA
Mailing Address - Zip Code:24091-2976
Mailing Address - Country:US
Mailing Address - Phone:352-361-1158
Mailing Address - Fax:
Practice Address - Street 1:3208 HERSHBERGER RD NW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24017-1842
Practice Address - Country:US
Practice Address - Phone:540-912-4211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-16
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)