Provider Demographics
NPI:1578717138
Name:REYNOLDS, MARCIE
Entity Type:Individual
Prefix:PROF
First Name:MARCIE
Middle Name:
Last Name:REYNOLDS
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 1:33 W ONTARIO ST
Mailing Address - Street 2:UNIT 32D
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-7760
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:33 W ONTARIO ST
Practice Address - Street 2:UNIT 32D
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-7760
Practice Address - Country:US
Practice Address - Phone:414-507-2580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-10
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4689-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist