Provider Demographics
NPI:1912130295
Name:REYNOLDS, ANDREA MARIE (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:MARIE
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3402 CHERRY LYNN DR
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-7644
Mailing Address - Country:US
Mailing Address - Phone:701-215-2030
Mailing Address - Fax:
Practice Address - Street 1:2016 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-6342
Practice Address - Country:US
Practice Address - Phone:701-775-8934
Practice Address - Fax:701-757-4208
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-02
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1260235Z00000X
MN7602235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist