Provider Demographics
NPI:1467267161
Name:REYNOLDS, QUENTIN LASHAWN
Entity type:Individual
Prefix:
First Name:QUENTIN
Middle Name:LASHAWN
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2515 HOGAN RD
Mailing Address - Street 2:
Mailing Address - City:EAST POINT
Mailing Address - State:GA
Mailing Address - Zip Code:30344-3824
Mailing Address - Country:US
Mailing Address - Phone:678-949-1158
Mailing Address - Fax:
Practice Address - Street 1:2515 HOGAN RD
Practice Address - Street 2:
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-3824
Practice Address - Country:US
Practice Address - Phone:678-949-1158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-10
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-24-383451106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician