Provider Demographics
NPI:1164080842
Name:REYNOLDS, BENJAMIN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
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 1:2031 OLD SALTS RD
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-4547
Mailing Address - Country:US
Mailing Address - Phone:360-643-3273
Mailing Address - Fax:
Practice Address - Street 1:204 BELLAIRE DR
Practice Address - Street 2:
Practice Address - City:NICHOLASVILLE
Practice Address - State:KY
Practice Address - Zip Code:40356-8840
Practice Address - Country:US
Practice Address - Phone:360-643-3273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-29
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY006909225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist