Provider Demographics
NPI:1962690347
Name:REYNOLDS, EDNA BETH II
Entity type:Individual
Prefix:MRS
First Name:EDNA
Middle Name:BETH
Last Name:REYNOLDS
Suffix:II
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 1:4490 WILLIAMS AVENUE
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942
Mailing Address - Country:US
Mailing Address - Phone:619-668-4200
Mailing Address - Fax:619-668-4281
Practice Address - Street 1:4490 WILLIAMS AVE
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942
Practice Address - Country:US
Practice Address - Phone:619-668-4200
Practice Address - Fax:619-668-4281
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-10
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)