Provider Demographics
NPI:1659823169
Name:REYNOLDS, CARRA
Entity type:Individual
Prefix:
First Name:CARRA
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 FORD DR
Mailing Address - Street 2:
Mailing Address - City:LINCOLN UNIVERSITY
Mailing Address - State:PA
Mailing Address - Zip Code:19352-9030
Mailing Address - Country:US
Mailing Address - Phone:443-945-0015
Mailing Address - Fax:
Practice Address - Street 1:127 FORD DR
Practice Address - Street 2:
Practice Address - City:LINCOLN UNIVERSITY
Practice Address - State:PA
Practice Address - Zip Code:19352-9030
Practice Address - Country:US
Practice Address - Phone:443-945-0015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-31
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG01230225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist