Provider Demographics
NPI:1740453828
Name:REYNOLDS, BRIAN W (PHD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:W
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9520
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79995-9520
Mailing Address - Country:US
Mailing Address - Phone:915-783-8164
Mailing Address - Fax:915-783-8187
Practice Address - Street 1:11950 BOB MITCHELL DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-4553
Practice Address - Country:US
Practice Address - Phone:915-856-5760
Practice Address - Fax:915-783-8187
Is Sole Proprietor?:No
Enumeration Date:2008-04-09
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX50733231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX080186AOtherBLUE CROSS BLUESHIELD TX
TX094628703Medicaid
TX080186AOtherBLUE CROSS BLUESHIELD TX