Provider Demographics
NPI:1992871362
Name:REYNOLDS, KELLY L (MSPT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:724 COMMERCIAL ST
Mailing Address - Street 2:
Mailing Address - City:ROCKPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04856-4201
Mailing Address - Country:US
Mailing Address - Phone:207-596-0374
Mailing Address - Fax:207-596-0375
Practice Address - Street 1:724 COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:ME
Practice Address - Zip Code:04856-4201
Practice Address - Country:US
Practice Address - Phone:207-596-0374
Practice Address - Fax:207-596-0375
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2010-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT2794225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1235215070Medicaid
ME1235215070Medicaid