Healthcare Provider Details

I. General information

NPI: 1114802493
Provider Name (Legal Business Name): REESE NICOLE PETRY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2025
Last Update Date: 08/07/2025
Certification Date: 08/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 W PINE ST
FREMONT MI
49412-1532
US

IV. Provider business mailing address

1049 E NEWELL ST
WHITE CLOUD MI
49349-8795
US

V. Phone/Fax

Practice location:
  • Phone: 231-760-9247
  • Fax: 231-760-9247
Mailing address:
  • Phone: 231-689-7330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: