Provider Demographics
NPI:1144227844
Name:REYNOLDS, JOHN MARTIN (MSW)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:MARTIN
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 S MELDRUM ST
Mailing Address - Street 2:PO BOX 343
Mailing Address - City:FT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80521-2071
Mailing Address - Country:US
Mailing Address - Phone:970-484-3494
Mailing Address - Fax:
Practice Address - Street 1:205 S MELDRUM ST
Practice Address - Street 2:
Practice Address - City:FT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80521-2071
Practice Address - Country:US
Practice Address - Phone:970-484-3494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9893131041C0700X
WY0831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY304151OtherBLUE SHIELD NUMBER
WYW306841Medicare PIN
COC62356Medicare PIN