Provider Demographics
NPI:1578601415
Name:REYNOLDS, STACEY ELLICE (OTRL)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:ELLICE
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1509 WENTBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23227-4730
Mailing Address - Country:US
Mailing Address - Phone:410-241-2140
Mailing Address - Fax:804-828-0782
Practice Address - Street 1:40 BROAD STREET RD
Practice Address - Street 2:
Practice Address - City:MANAKIN SABOT
Practice Address - State:VA
Practice Address - Zip Code:23103-2213
Practice Address - Country:US
Practice Address - Phone:804-784-3514
Practice Address - Fax:804-784-4514
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119004113225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics