Provider Demographics
NPI:1821465717
Name:REYNOLDS, DANIEL GLENN (PTA)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:GLENN
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3161 BLACKWATER OAKS WAY
Mailing Address - Street 2:
Mailing Address - City:MULBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:33860-5552
Mailing Address - Country:US
Mailing Address - Phone:863-899-3621
Mailing Address - Fax:
Practice Address - Street 1:2701 LAKE ALFRED RD
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-1432
Practice Address - Country:US
Practice Address - Phone:863-298-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-26
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 26021225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant