Provider Demographics
NPI:1134189293
Name:REYNOLDS, ERICA MARIE (PT)
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:MARIE
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 N WALL ST
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-2901
Mailing Address - Country:US
Mailing Address - Phone:815-935-7514
Mailing Address - Fax:815-935-7069
Practice Address - Street 1:350 N WALL ST
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-2901
Practice Address - Country:US
Practice Address - Phone:815-935-7514
Practice Address - Fax:815-935-7069
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05007435A225100000X
IL070.014188225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000219707OtherANTHEM PROVIDER NUMBER
IN200364140Medicaid