=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518197771
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BEATRICE REYNOLDS PT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2009
-----------------------------------------------------
Last Update Date | 07/22/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 112 ANCHORAGE CIR
-----------------------------------------------------
City | GROTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06340-5430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-705-8914
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 112 ANCHORAGE CIR
-----------------------------------------------------
City | GROTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06340-5430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-705-8914
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251P0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Physical Therapist
-----------------------------------------------------
License Number | 000952
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------