Provider Demographics
NPI:1063431872
Name:REYNOLDS, RANDAL DAVID (PHD)
Entity type:Individual
Prefix:DR
First Name:RANDAL
Middle Name:DAVID
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4401 WESTOWN PKWY
Mailing Address - Street 2:SUITE 309
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-6721
Mailing Address - Country:US
Mailing Address - Phone:515-440-3801
Mailing Address - Fax:515-440-3701
Practice Address - Street 1:4401 WESTOWN PKWY
Practice Address - Street 2:SUITE 309
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-6721
Practice Address - Country:US
Practice Address - Phone:515-440-3801
Practice Address - Fax:515-440-3701
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00993103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0467068Medicaid
IAI16413Medicare ID - Type Unspecified