Basic Information
| Provider Information | |||||||||
| NPI: | 1245545953 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REYNOLDS | ||||||||
| FirstName: | PATRICIA | ||||||||
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| Credential: | M.A.CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19009 BARTOW BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339673560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5184205019 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3950 3RD STREET NORTH, SUITE D | ||||||||
| Address2: | COMMUNITY REHAB ASSOCIATES | ||||||||
| City: | ST. PETERSBURG, FL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8772684329 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2010 | ||||||||
| LastUpdateDate: | 12/14/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 016945 | NY | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.