Provider Demographics
NPI:1508615386
Name:REYNOSO, GRACIELA (OTD, OTR/L)
Entity type:Individual
Prefix:
First Name:GRACIELA
Middle Name:
Last Name:REYNOSO
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 JAMES CT UNIT D
Mailing Address - Street 2:
Mailing Address - City:GLENDALE HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60139-3245
Mailing Address - Country:US
Mailing Address - Phone:630-386-6484
Mailing Address - Fax:
Practice Address - Street 1:1371 ABBOTT CT STE A
Practice Address - Street 2:
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089-2367
Practice Address - Country:US
Practice Address - Phone:847-777-8995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-15
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056015671225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist