Provider Demographics
NPI:1336455088
Name:REYNOLDS, KATHLEEN GLORIA (MS,PT)
Entity type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:GLORIA
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:MS,PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-5308
Mailing Address - Country:US
Mailing Address - Phone:516-578-7882
Mailing Address - Fax:
Practice Address - Street 1:160 E 4TH ST
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729-5308
Practice Address - Country:US
Practice Address - Phone:516-578-7882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-19
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012091-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist