Provider Demographics
NPI:1265629919
Name:REYNOLDS, COLLIN (CCC SLP)
Entity Type:Individual
Prefix:
First Name:COLLIN
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 W PROVIDENCE AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3808
Mailing Address - Country:US
Mailing Address - Phone:714-923-1527
Mailing Address - Fax:714-744-3841
Practice Address - Street 1:1801 NW VESPER ST
Practice Address - Street 2:
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64015-3219
Practice Address - Country:US
Practice Address - Phone:816-224-1487
Practice Address - Fax:816-224-1310
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-26
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0348199235Z00000X
CA19027235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist