Provider Demographics
NPI:1932479060
Name:REYNOLDS, INDIA REID (PT, CWS, MS)
Entity Type:Individual
Prefix:
First Name:INDIA
Middle Name:REID
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:PT, CWS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2453 FIDDLERS GLENN DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27127-5940
Mailing Address - Country:US
Mailing Address - Phone:336-788-1119
Mailing Address - Fax:336-788-1145
Practice Address - Street 1:2453 FIDDLERS GLENN DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27127-5940
Practice Address - Country:US
Practice Address - Phone:336-788-1119
Practice Address - Fax:336-788-1145
Is Sole Proprietor?:No
Enumeration Date:2012-01-05
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8176225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7213053Medicaid
NC6730090001Medicare NSC