Provider Demographics
NPI:1659912764
Name:REYNOLDS, ANDREA MCGANN (OT)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:MCGANN
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:CLAIRE
Other - Last Name:MCGANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:PO BOX 720610
Mailing Address - Street 2:
Mailing Address - City:BYRAM
Mailing Address - State:MS
Mailing Address - Zip Code:39272-0610
Mailing Address - Country:US
Mailing Address - Phone:601-308-5117
Mailing Address - Fax:601-308-5103
Practice Address - Street 1:950 E COUNTY LINE RD STE A
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-1928
Practice Address - Country:US
Practice Address - Phone:016-308-5117
Practice Address - Fax:601-308-5103
Is Sole Proprietor?:No
Enumeration Date:2019-10-01
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT3297225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist