Provider Demographics
NPI:1083919948
Name:REYNOLDS, RADIAH
Entity Type:Individual
Prefix:
First Name:RADIAH
Middle Name:
Last Name:REYNOLDS
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 1:500 AMITY RD SUITE 5B #139
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72032
Mailing Address - Country:US
Mailing Address - Phone:870-550-7003
Mailing Address - Fax:870-550-7003
Practice Address - Street 1:2825 CLOVER LN
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-8997
Practice Address - Country:US
Practice Address - Phone:870-550-7003
Practice Address - Fax:501-358-3785
Is Sole Proprietor?:No
Enumeration Date:2011-01-24
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP#8398235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist