Basic Information
Provider Information | |||||||||
NPI: | 1952701815 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | REYNOLDS | ||||||||
FirstName: | KRISTEN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WHEELER | ||||||||
OtherFirstName: | KRISTEN | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1900 MIDLAND TRL | ||||||||
Address2: | SUITE 1 AND 2 | ||||||||
City: | SHELBYVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 400658141 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5026331007 | ||||||||
FaxNumber: | 5024370624 | ||||||||
Practice Location | |||||||||
Address1: | 90 HOWARD DR | ||||||||
Address2: |   | ||||||||
City: | SHELBYVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 400658138 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5026331007 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/28/2014 | ||||||||
LastUpdateDate: | 06/12/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 3741 | KY | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
No ID Information.