Provider Demographics
NPI:1003951716
Name:REYNOLDS, ELIZABETH J (DPT)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:J
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1906 NW 25TH AVE
Mailing Address - Street 2:#3
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-2567
Mailing Address - Country:US
Mailing Address - Phone:503-229-8009
Mailing Address - Fax:
Practice Address - Street 1:4709 N LAGOON AVE
Practice Address - Street 2:A
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-7741
Practice Address - Country:US
Practice Address - Phone:503-445-4929
Practice Address - Fax:503-517-0206
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4838225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist