Provider Demographics
NPI:1053782938
Name:REYNOLDS, CHARLES HENRY SR (MRE, CADC I)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:HENRY
Last Name:REYNOLDS
Suffix:SR
Gender:M
Credentials:MRE, CADC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 NE 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-3508
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:503-595-3478
Practice Address - Street 1:504 NE 18TH AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-3508
Practice Address - Country:US
Practice Address - Phone:503-348-6425
Practice Address - Fax:503-595-3478
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-16
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
OR15-09-18101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health