Provider Demographics
NPI:1689718355
Name:REYNOLDS, BREANNA CATHERINE (PT)
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:CATHERINE
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 1:850 43RD AVE
Mailing Address - Street 2:STE. 100
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-8401
Mailing Address - Country:US
Mailing Address - Phone:309-743-2070
Mailing Address - Fax:
Practice Address - Street 1:850 43RD AVE
Practice Address - Street 2:STE. 100
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-8401
Practice Address - Country:US
Practice Address - Phone:309-743-2070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070012773225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist