Provider Demographics
NPI:1407314693
Name:REYNOLDS, AUTUMN (DPT)
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:AUTUMN
Other - Middle Name:
Other - Last Name:MATTIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1405 HILLSBORO BLVD
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37355-2107
Mailing Address - Country:US
Mailing Address - Phone:931-954-1020
Mailing Address - Fax:615-221-9054
Practice Address - Street 1:1405 HILLSBORO BLVD
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37355-2107
Practice Address - Country:US
Practice Address - Phone:931-954-1020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-06
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12521225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ029723Medicaid