Healthcare Provider Details

I. General information

NPI: 1790011195
Provider Name (Legal Business Name): SUSAN REED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2009
Last Update Date: 10/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4020 N GREY WOLF DR
WASILLA AK
99654-1837
US

IV. Provider business mailing address

4020 N GREY WOLF DR
WASILLA AK
99654-1837
US

V. Phone/Fax

Practice location:
  • Phone: 907-357-7395
  • Fax: 907-357-9599
Mailing address:
  • Phone: 907-357-7395
  • Fax: 907-357-9599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number435062
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1013126929
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer

VIII. Authorized Official

Name: MISS SUSAN REED
Title or Position: CARE COORDINATOR
Credential:
Phone: 907-357-7395