Provider Demographics
NPI:1285913194
Name:REYNOLDS, SHEILA DIXON (O)
Entity type:Individual
Prefix:MS
First Name:SHEILA
Middle Name:DIXON
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:O
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3981 SPRINGFIELD ROADD
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:GA
Mailing Address - Zip Code:31087
Mailing Address - Country:US
Mailing Address - Phone:706-486-4051
Mailing Address - Fax:
Practice Address - Street 1:3981 SPRINGFIELD RD
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:GA
Practice Address - Zip Code:31087-3343
Practice Address - Country:US
Practice Address - Phone:706-486-4051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-09
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA372600000X104100000X
GA033924586172V00000X, 305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA033924586Medicaid