Provider Demographics
NPI:1699982025
Name:REYNOLDS, DANIEL (PT)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8725 N WICKHAM RD
Practice Address - Street 2:SUITE 301
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-5997
Practice Address - Country:US
Practice Address - Phone:321-434-9200
Practice Address - Fax:321-434-9202
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21944225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU5421XOtherMEDICARE
FLP01425141OtherFL RR