Provider Demographics
NPI:1174885743
Name:REYNOLDS, BREANNE CASEY (SLP)
Entity type:Individual
Prefix:
First Name:BREANNE
Middle Name:CASEY
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12158 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:MITCHELLVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-1932
Mailing Address - Country:US
Mailing Address - Phone:301-390-3076
Mailing Address - Fax:301-390-3725
Practice Address - Street 1:102 IRVING ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20010-2921
Practice Address - Country:US
Practice Address - Phone:301-540-6140
Practice Address - Fax:301-540-5190
Is Sole Proprietor?:No
Enumeration Date:2012-06-11
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD07317235Z00000X
235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist