Provider Demographics
NPI:1225810401
Name:REYNOLDS, HERBERT ALLEN III (OTA)
Entity Type:Individual
Prefix:
First Name:HERBERT
Middle Name:ALLEN
Last Name:REYNOLDS
Suffix:III
Gender:M
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:WINTERPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04496-3447
Mailing Address - Country:US
Mailing Address - Phone:207-249-5293
Mailing Address - Fax:
Practice Address - Street 1:103 TEXAS AVE
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-4324
Practice Address - Country:US
Practice Address - Phone:207-947-4557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-20
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224Z00000X
MEOA1810224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant