Provider Demographics
NPI:1114356235
Name:REYNOLDS, MEGAN (PTA)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38626 MATTIX RD
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:OH
Mailing Address - Zip Code:44432-9704
Mailing Address - Country:US
Mailing Address - Phone:330-429-1386
Mailing Address - Fax:
Practice Address - Street 1:400 CAROLYN CT
Practice Address - Street 2:
Practice Address - City:MINERVA
Practice Address - State:OH
Practice Address - Zip Code:44657-8703
Practice Address - Country:US
Practice Address - Phone:330-868-4104
Practice Address - Fax:330-868-7714
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-08
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA. 08530225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant