Basic Information
| Provider Information | |||||||||
| NPI: | 1710334206 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REYNOLDS | ||||||||
| FirstName: | ROXANNA | ||||||||
| MiddleName: | |||||||||
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| Credential: | LAC | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 630 W MERCURY ST | ||||||||
| Address2: | |||||||||
| City: | BUTTE | ||||||||
| State: | MT | ||||||||
| PostalCode: | 597011510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062993448 | ||||||||
| FaxNumber: | 4062993450 | ||||||||
| Practice Location | |||||||||
| Address1: | 630 W MERCURY ST | ||||||||
| Address2: | |||||||||
| City: | BUTTE | ||||||||
| State: | MT | ||||||||
| PostalCode: | 597011510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062993448 | ||||||||
| FaxNumber: | 4062993450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2016 | ||||||||
| LastUpdateDate: | 05/16/2016 | ||||||||
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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 | 101YA0400X | LAC-LAC-LIC-1240 | MT | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.