Provider Demographics
NPI:1063877793
Name:REYNOLDS, KENNETH (PT, DPT)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10767 ILLINOIS ST STE 3000
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-8972
Mailing Address - Country:US
Mailing Address - Phone:317-817-1200
Mailing Address - Fax:317-817-1220
Practice Address - Street 1:10767 ILLINOIS ST STE 3000
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-8972
Practice Address - Country:US
Practice Address - Phone:317-817-1200
Practice Address - Fax:317-817-1220
Is Sole Proprietor?:No
Enumeration Date:2015-12-22
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011021992225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist