Provider Demographics
NPI:1013388073
Name:REYNOLDS, MARK RICHARD (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:RICHARD
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 WOODLAND ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-2325
Mailing Address - Country:US
Mailing Address - Phone:860-522-2717
Mailing Address - Fax:860-240-7605
Practice Address - Street 1:36 WOODLAND ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-2325
Practice Address - Country:US
Practice Address - Phone:860-522-2717
Practice Address - Fax:860-240-7605
Is Sole Proprietor?:No
Enumeration Date:2015-10-15
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT010587225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist