Provider Demographics
NPI:1457748857
Name:REYNOLDS, CRYSTAL ALESE (MS, ATC)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ALESE
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1871 MONTCLAIR DR
Mailing Address - Street 2:UNIT A
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-7544
Mailing Address - Country:US
Mailing Address - Phone:434-987-6414
Mailing Address - Fax:
Practice Address - Street 1:1871 MONTCLAIR DR
Practice Address - Street 2:UNIT A
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-7544
Practice Address - Country:US
Practice Address - Phone:434-987-6414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-23
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11992255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer