MEDICARE: MS. ELIZABETH J REYNOLDS DPT

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	225100000X	Physical Therapist	4838	OR

General Provider Information

NPI Number	:	1003951716
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ELIZABETH J REYNOLDS DPT

Provider Business Mailing Address
First Line	:	1906 NW 25TH AVE
Second Line	:	#3
City	:	PORTLAND
State	:	OR
Zip	:	97210-2567
Country	:	US
Telephone Number	:	503-229-8009
Fax Number	:

Provider Business Practice Location Address
First Line	:	4709 N LAGOON AVE
Second Line	:	A
City	:	PORTLAND
State	:	OR
Zip	:	97217-7741
Country	:	US
Telephone Number	:	503-445-4929
Fax Number	:	503-517-0206

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

Provider Enumeration Date	:	02/20/2007
Last Update Date	:	07/08/2007

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