Provider Demographics
NPI:1417463670
Name:REYNOLDS, REBECCA JANE (ATC)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:JANE
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1924 N 630 E
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84097-2396
Mailing Address - Country:US
Mailing Address - Phone:616-334-2116
Mailing Address - Fax:
Practice Address - Street 1:1924 N 630 E
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84097-2396
Practice Address - Country:US
Practice Address - Phone:616-334-2116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-22
Last Update Date:2017-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10511091-48102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer