Provider Demographics
NPI:1861528622
Name:REYNOLDS, LAURA JEAN (MS,PT)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:JEAN
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:MS,PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 919
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:CT
Mailing Address - Zip Code:06413-0919
Mailing Address - Country:US
Mailing Address - Phone:860-669-5438
Mailing Address - Fax:
Practice Address - Street 1:180 WESTBROOK RD
Practice Address - Street 2:UNIT 3
Practice Address - City:ESSEX
Practice Address - State:CT
Practice Address - Zip Code:06426-1517
Practice Address - Country:US
Practice Address - Phone:860-767-7587
Practice Address - Fax:860-767-7587
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3779225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT650001375Medicare ID - Type Unspecified