Provider Demographics
NPI:1306490321
Name:REYNOLDS, ELIZABETH
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 MAIN ST UNIT 3
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:CT
Mailing Address - Zip Code:06468-2830
Mailing Address - Country:US
Mailing Address - Phone:203-449-7908
Mailing Address - Fax:203-418-2086
Practice Address - Street 1:755 MAIN ST UNIT 3
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:CT
Practice Address - Zip Code:06468-2830
Practice Address - Country:US
Practice Address - Phone:203-449-7908
Practice Address - Fax:203-418-2086
Is Sole Proprietor?:No
Enumeration Date:2019-07-29
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3790101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health