Basic Information
| Provider Information | |||||||||
| NPI: | 1063080463 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REYNOLDS | ||||||||
| FirstName: | IMANI | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | CT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11020 PRINCE AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441052748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2167988384 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1293 COPLEY RD | ||||||||
| Address2: | |||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443202766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303741199 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2021 | ||||||||
| LastUpdateDate: | 06/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | C.2103249-TRNE | OH | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.