1053476515 NPI number — MR. MARK WILLIAM REICH MS PSYCHOLOGY

Table of content: MR. MARK WILLIAM REICH MS PSYCHOLOGY (NPI 1053476515)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053476515 NPI number — MR. MARK WILLIAM REICH MS PSYCHOLOGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REICH
Provider First Name:
MARK
Provider Middle Name:
WILLIAM
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MS PSYCHOLOGY
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
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Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053476515
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
W2510 VALLEYWOOD LANE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
APPLETON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54915
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-788-5261
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
103 WEST COLLEGE AVENUE
Provider Second Line Business Practice Location Address:
SUITE 815
Provider Business Practice Location Address City Name:
APPLETON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54911
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-733-1992
Provider Business Practice Location Address Fax Number:
920-733-1866
Provider Enumeration Date:
12/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
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Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  2551123 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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