Provider Demographics
NPI:1407824048
Name:REYNOLDS, MARY JO (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JO
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 BRIARCREEK LN
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711-7219
Mailing Address - Country:US
Mailing Address - Phone:217-341-2202
Mailing Address - Fax:
Practice Address - Street 1:315 8TH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:IL
Practice Address - Zip Code:62656-2671
Practice Address - Country:US
Practice Address - Phone:217-732-2161
Practice Address - Fax:217-732-3101
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-09
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL7007311225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist