Provider Demographics
NPI:1235508490
Name:REYNOLDS, SHANNON D (LMT)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:D
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 FAIRFIELD RD APT A
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06830-4889
Mailing Address - Country:US
Mailing Address - Phone:203-610-2886
Mailing Address - Fax:203-916-4601
Practice Address - Street 1:8 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:CT
Practice Address - Zip Code:06880-4201
Practice Address - Country:US
Practice Address - Phone:203-916-4600
Practice Address - Fax:201-916-4601
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-17
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT008190174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist