Provider Demographics
NPI:1306981006
Name:REYNOLDS, JAMES MARK (PHD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:MARK
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 LAKE ROAD
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:NY
Mailing Address - Zip Code:14519
Mailing Address - Country:US
Mailing Address - Phone:585-506-7071
Mailing Address - Fax:
Practice Address - Street 1:1519 NYE ROAD
Practice Address - Street 2:WAYNE BEHAVIORAL HEALTH NETWORK
Practice Address - City:LYONS
Practice Address - State:NY
Practice Address - Zip Code:14489
Practice Address - Country:US
Practice Address - Phone:315-946-5722
Practice Address - Fax:315-946-7066
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013321103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist