Provider Demographics
NPI:1477299691
Name:REYNOLDS-TODD, DETRA
Entity Type:Individual
Prefix:
First Name:DETRA
Middle Name:
Last Name:REYNOLDS-TODD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:941 E RAYMOND ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46203-3919
Mailing Address - Country:US
Mailing Address - Phone:317-728-4239
Mailing Address - Fax:
Practice Address - Street 1:9770 JACKSON WAY
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-9588
Practice Address - Country:US
Practice Address - Phone:317-728-4239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-10
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child