Healthcare Provider Details

I. General information

NPI: 1093070989
Provider Name (Legal Business Name): HEATHER MCREYNOLDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2012
Last Update Date: 03/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15158 HUNTINGTON CT
ORLAND PARK IL
60462-3544
US

IV. Provider business mailing address

15158 HUNTINGTON CT
ORLAND PARK IL
60462-3544
US

V. Phone/Fax

Practice location:
  • Phone: 708-307-5462
  • Fax:
Mailing address:
  • Phone: 708-307-5462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.020035
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: