Healthcare Provider Details

I. General information

NPI: 1194695155
Provider Name (Legal Business Name): ARIANNA REISS LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2025
Last Update Date: 11/06/2025
Certification Date: 10/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

904 E MARTIN LUTHER KING DRIVE
CENTRALIA IL
62801
US

IV. Provider business mailing address

3005 CHERRY ST
MOUNT VERNON IL
62864-2405
US

V. Phone/Fax

Practice location:
  • Phone: 618-533-1391
  • Fax: 618-533-0012
Mailing address:
  • Phone: 618-533-1391
  • Fax: 618-533-0012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number150117622
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: