Provider Demographics
NPI:1952510075
Name:REYNOLDS, MICHAEL (OTR)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 N ARMOUR ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-2033
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1947 N FOUNDERS CIR
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-3548
Practice Address - Country:US
Practice Address - Phone:316-613-5380
Practice Address - Fax:316-613-5385
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2018-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS17-02009225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist