Provider Demographics
NPI:1396161113
Name:REYNOLDS, DAVA
Entity type:Individual
Prefix:
First Name:DAVA
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2632 SAINT ANDREWS DR
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:TX
Mailing Address - Zip Code:75146-1193
Mailing Address - Country:US
Mailing Address - Phone:469-688-0237
Mailing Address - Fax:972-230-2736
Practice Address - Street 1:2535 LONE STAR DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75212-6313
Practice Address - Country:US
Practice Address - Phone:214-467-9787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-17
Last Update Date:2024-05-16
Deactivation Date:2020-12-08
Deactivation Code:
Reactivation Date:2024-05-16
Provider Licenses
StateLicense IDTaxonomies
TX108342235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist