Healthcare Provider Details

I. General information

NPI: 1255875365
Provider Name (Legal Business Name): DAWN LEANNE REAGOR L.L.P.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2016
Last Update Date: 06/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

97 S 4TH ST STE A
ISHPEMING MI
49849-2168
US

IV. Provider business mailing address

97 S 4TH ST
ISHPEMING MI
49849-2168
US

V. Phone/Fax

Practice location:
  • Phone: 906-228-9699
  • Fax: 906-228-0505
Mailing address:
  • Phone: 906-228-9699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401015835
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: