Provider Demographics
NPI:1730699620
Name:REYNOLDS, CASSANDRA GRACE (COTA/L)
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:GRACE
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 CROSBY DR APT 102
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40515-1858
Mailing Address - Country:US
Mailing Address - Phone:513-600-9979
Mailing Address - Fax:
Practice Address - Street 1:3900 CROSBY DR APT 102
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40515
Practice Address - Country:US
Practice Address - Phone:513-600-9979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-04
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7137224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant