Basic Information
| Provider Information | |||||||||
| NPI: | 1134542889 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REYNOLDS | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1016 SW 44TH ST STE 500 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731093615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056054249 | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 S BROADWAY STE 15 | ||||||||
| Address2: | |||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730343848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4055624891 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2014 | ||||||||
| LastUpdateDate: | 11/30/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 5931 | OK | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 200522860A | 05 | OK | MEDICAID |