Provider Demographics
NPI:1649835406
Name:REYNOLDS, PHILLIP ANTHONY
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:ANTHONY
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 BRONCO CT
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20874-6159
Mailing Address - Country:US
Mailing Address - Phone:301-325-2251
Mailing Address - Fax:
Practice Address - Street 1:8120 WOODMONT AVE STE 205
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-2784
Practice Address - Country:US
Practice Address - Phone:202-906-9588
Practice Address - Fax:202-403-3200
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-07
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD145431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty