Basic Information
| Provider Information | |||||||||
| NPI: | 1538660576 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REYNOLDS | ||||||||
| FirstName: | ANDREW | ||||||||
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| Credential: | PT, DPT, CSCS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 416495 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022418480 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6315805200 | ||||||||
| FaxNumber: | 6315805222 | ||||||||
| Practice Location | |||||||||
| Address1: | 109 ROUTE 46 | ||||||||
| Address2: | |||||||||
| City: | DENVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 078342776 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9736250744 | ||||||||
| FaxNumber: | 9736250741 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2018 | ||||||||
| LastUpdateDate: | 06/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 40QA01777700 | NJ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.