Provider Demographics
NPI:1104971340
Name:REYNOLDS, ILENE (SLP)
Entity type:Individual
Prefix:MS
First Name:ILENE
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 ANCHORAGE DR
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-5010
Mailing Address - Country:US
Mailing Address - Phone:631-422-5462
Mailing Address - Fax:631-422-3111
Practice Address - Street 1:180 ANCHORAGE DR
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-5010
Practice Address - Country:US
Practice Address - Phone:631-422-5462
Practice Address - Fax:631-422-3111
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2572235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist