Provider Demographics
NPI:1285804377
Name:REYNOLDS, CHARLES NORMAN (MSW)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:NORMAN
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 GROSSCUP AVE
Mailing Address - Street 2:
Mailing Address - City:DUNBAR
Mailing Address - State:WV
Mailing Address - Zip Code:25064-3128
Mailing Address - Country:US
Mailing Address - Phone:304-766-7336
Mailing Address - Fax:304-525-1073
Practice Address - Street 1:1020 GROSSCUP AVE
Practice Address - Street 2:
Practice Address - City:DUNBAR
Practice Address - State:WV
Practice Address - Zip Code:25064-3128
Practice Address - Country:US
Practice Address - Phone:304-766-7336
Practice Address - Fax:304-525-1073
Is Sole Proprietor?:No
Enumeration Date:2008-03-05
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAP00451774104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0005355002Medicaid