Provider Demographics
NPI:1902023948
Name:REYNOLDS, ROBERT WILLIAM (PTA)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:WILLIAM
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 1:1559 STARGAZER TER
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-9202
Mailing Address - Country:US
Mailing Address - Phone:407-506-2483
Mailing Address - Fax:
Practice Address - Street 1:451 S AMELIA AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32724-5917
Practice Address - Country:US
Practice Address - Phone:407-506-2483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 19695225200000X
MEPA2263225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant