Provider Demographics
NPI:1679966998
Name:REYNOLDS, CRYSTAL NICOLE (MS, OTR/L)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:NICOLE
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:NICOLE
Other - Last Name:BETANCOURT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, OTR/L
Mailing Address - Street 1:2384 GARDEN HILLS LOOP
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:GA
Mailing Address - Zip Code:31324-6091
Mailing Address - Country:US
Mailing Address - Phone:912-663-4118
Mailing Address - Fax:912-330-1071
Practice Address - Street 1:2384 GARDEN HILLS LOOP
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:GA
Practice Address - Zip Code:31324-6091
Practice Address - Country:US
Practice Address - Phone:912-663-4118
Practice Address - Fax:912-330-1071
Is Sole Proprietor?:No
Enumeration Date:2015-03-11
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT005053225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist