Provider Demographics
NPI:1922506005
Name:REYNOLDS, LUCIA NICHOLE (LMT, BCTMB)
Entity Type:Individual
Prefix:
First Name:LUCIA
Middle Name:NICHOLE
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:LMT, BCTMB
Other - Prefix:
Other - First Name:LUCIA
Other - Middle Name:NICHOLE
Other - Last Name:RUIZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1210 COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:MACHESNEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61115-3808
Mailing Address - Country:US
Mailing Address - Phone:815-560-2862
Mailing Address - Fax:
Practice Address - Street 1:2606 BROADWAY
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-5768
Practice Address - Country:US
Practice Address - Phone:815-397-3744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-24
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL220.014395225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist