Provider Demographics
NPI:1417361049
Name:REYNOLDS, MITCHELL J (PT)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:J
Last Name:REYNOLDS
Suffix:
Gender:M
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:PO BOX 32569
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37930-2569
Mailing Address - Country:US
Mailing Address - Phone:865-694-0062
Mailing Address - Fax:865-694-7907
Practice Address - Street 1:9430 PARK WEST BLVD
Practice Address - Street 2:SUITE 230
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4200
Practice Address - Country:US
Practice Address - Phone:865-690-4861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-11
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9993225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ007022Medicaid
0677340003Medicare NSC
103I654144Medicare PIN
0677340002Medicare NSC
TN103I654013Medicare PIN
103I654142Medicare PIN
0677340004Medicare NSC
103I654141Medicare PIN
0677340001Medicare NSC
0677340005Medicare NSC