Provider Demographics
NPI:1598836918
Name:REYNOLDS, LISA A (PT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3188 SILER CTY SNOW CP RD
Mailing Address - Street 2:
Mailing Address - City:SILER CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27344-7232
Mailing Address - Country:US
Mailing Address - Phone:919-663-4585
Mailing Address - Fax:888-220-3443
Practice Address - Street 1:3188 SILER CTY SNOW CP RD
Practice Address - Street 2:
Practice Address - City:SILER CITY
Practice Address - State:NC
Practice Address - Zip Code:27344-7232
Practice Address - Country:US
Practice Address - Phone:919-663-4585
Practice Address - Fax:888-220-3443
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3465225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC71343OtherBCBS
NC7271343Medicaid