Provider Demographics
NPI:1093877060
Name:REYNOLDS, TERESA MARIE (PT, MBA)
Entity Type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:MARIE
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:PT, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 MORGANTOWN ST
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26537-1095
Mailing Address - Country:US
Mailing Address - Phone:304-789-2152
Mailing Address - Fax:
Practice Address - Street 1:421 MORGANTOWN ST
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:WV
Practice Address - Zip Code:26537-1095
Practice Address - Country:US
Practice Address - Phone:304-789-2152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV000482225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0158059000Medicaid
WV0158059000Medicaid