Basic Information
| Provider Information | |||||||||
| NPI: | 1265552681 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REYNOLDS | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | L.C.P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 819 BUSSE HWY | ||||||||
| Address2: | MAINE CENTER | ||||||||
| City: | PARK RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600682360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476961376 | ||||||||
| FaxNumber: | 8476961587 | ||||||||
| Practice Location | |||||||||
| Address1: | 819 BUSSE HWY | ||||||||
| Address2: | MAINE CENTER | ||||||||
| City: | PARK RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600682360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476961376 | ||||||||
| FaxNumber: | 8476961587 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | IL | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.