Provider Demographics
NPI:1427718683
Name:REYNOLDS, CALLIE (PT, DPT)
Entity type:Individual
Prefix:MRS
First Name:CALLIE
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:MISS
Other - First Name:CALLIE
Other - Middle Name:
Other - Last Name:MYERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:PO BOX 416501
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-6501
Mailing Address - Country:US
Mailing Address - Phone:194-294-4050
Mailing Address - Fax:631-760-8306
Practice Address - Street 1:3755 N WATER ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-1858
Practice Address - Country:US
Practice Address - Phone:217-675-7111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-29
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.023956225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist