Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101Y00000X | Counselor | OR |
NPI | 1003189960 |
---|---|
Provider Name | Taylor Reynolds |
First Address | Portland, OR 97202-3371 |
Second Address | Corvallis, OR 97330-9695 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/02/2012 |
Last Update Date | 22/02/2012 |