Provider Demographics
NPI:1073874194
Name:REYNOSO, NATISHA
Entity Type:Individual
Prefix:
First Name:NATISHA
Middle Name:
Last Name:REYNOSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 DOGWOOD ST
Mailing Address - Street 2:
Mailing Address - City:WAVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39576-2003
Mailing Address - Country:US
Mailing Address - Phone:228-332-1094
Mailing Address - Fax:
Practice Address - Street 1:210 DOGWOOD ST
Practice Address - Street 2:
Practice Address - City:WAVELAND
Practice Address - State:MS
Practice Address - Zip Code:39576-2003
Practice Address - Country:US
Practice Address - Phone:228-332-1094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-05
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist