Provider Demographics
NPI:1477667236
Name:REYNOLDS, ETTA L (PT)
Entity Type:Individual
Prefix:MRS
First Name:ETTA
Middle Name:L
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 1:2763 E SHAW
Mailing Address - Street 2:# 102
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-8220
Mailing Address - Country:US
Mailing Address - Phone:559-294-8112
Mailing Address - Fax:559-294-7805
Practice Address - Street 1:2763 E SHAW
Practice Address - Street 2:# 102
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-8220
Practice Address - Country:US
Practice Address - Phone:559-294-8112
Practice Address - Fax:559-294-7805
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT88730225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PT88730Medicare ID - Type Unspecified