Provider Demographics
NPI:1003054313
Name:REID, JONATHAN ROBERT
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:ROBERT
Last Name:REID
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JONATHAN
Other - Middle Name:ROBERT
Other - Last Name:REID
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:170 INTREPID LANE
Mailing Address - Street 2:HIGH PEAKS
Mailing Address - City:SYRACUSES
Mailing Address - State:NY
Mailing Address - Zip Code:13205
Mailing Address - Country:US
Mailing Address - Phone:315-492-8319
Mailing Address - Fax:315-492-3758
Practice Address - Street 1:170 INTREPID LANE
Practice Address - Street 2:HIGH PEAKS
Practice Address - City:SYRACUSES
Practice Address - State:NY
Practice Address - Zip Code:13205
Practice Address - Country:US
Practice Address - Phone:315-492-8319
Practice Address - Fax:315-492-3758
Is Sole Proprietor?:No
Enumeration Date:2009-01-23
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014453-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist