Provider Demographics
NPI:1043464647
Name:REYNOLDS, MAXINE LORRAINE (MS, EDM CCC SP/A)
Entity type:Individual
Prefix:MRS
First Name:MAXINE
Middle Name:LORRAINE
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:MS, EDM CCC SP/A
Other - Prefix:MRS
Other - First Name:MAXINE
Other - Middle Name:LORRAINE
Other - Last Name:NEVERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:124 SCOTRUN DR
Mailing Address - Street 2:
Mailing Address - City:SCOTRUN
Mailing Address - State:PA
Mailing Address - Zip Code:18355-9657
Mailing Address - Country:US
Mailing Address - Phone:570-856-9599
Mailing Address - Fax:
Practice Address - Street 1:124 SCOTRUN DR
Practice Address - Street 2:
Practice Address - City:SCOTRUN
Practice Address - State:PA
Practice Address - Zip Code:18355-9657
Practice Address - Country:US
Practice Address - Phone:570-856-9599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-10
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY893-1231H00000X
NY4279235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologist