Provider Demographics
NPI:1972366110
Name:REYNOLDS, LAUREN CAMILLE
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:CAMILLE
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 1:579 ROAD 1093
Mailing Address - Street 2:
Mailing Address - City:PLANTERSVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38862-4906
Mailing Address - Country:US
Mailing Address - Phone:662-523-3450
Mailing Address - Fax:
Practice Address - Street 1:2164 SOUTHRIDGE DR
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6417
Practice Address - Country:US
Practice Address - Phone:662-760-0115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-31
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS104100000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS001437332Medicaid
MS834622726Medicaid