Basic Information
| Provider Information | |||||||||
| NPI: | 1881179208 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REYNOLDS | ||||||||
| FirstName: | COURTNEY | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 97 BRIGHTON RD | ||||||||
| Address2: | |||||||||
| City: | TONAWANDA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141506812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7165531741 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4242 RIDGE LEA RD | ||||||||
| Address2: | |||||||||
| City: | AMHERST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142261051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168192400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2018 | ||||||||
| LastUpdateDate: | 10/02/2018 | ||||||||
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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 | 171M00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.