MEDICARE: MRS. LISA MARIA REYNOLDS M.S., CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	17842	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	14568671	OTHER	TX	TX DRIVERS LICENSE

General Provider Information

NPI Number	:	1023768827
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISA MARIA REYNOLDS M.S., CCC-SLP

Provider Business Mailing Address
First Line	:	100 WALTER STEPHENSON RD
Second Line	:
City	:	MIDLOTHIAN
State	:	TX
Zip	:	76065-3699
Country	:	US
Telephone Number	:	469-644-9810
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 WALTER STEPHENSON RD
Second Line	:
City	:	MIDLOTHIAN
State	:	TX
Zip	:	76065-3699
Country	:	US
Telephone Number	:	469-644-9810
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/24/2022
Last Update Date	:	03/24/2022

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Directions to “ MRS. LISA MARIA REYNOLDS M.S., CCC-SLP” Practice Location

Language	Start Address	Practice Location

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