Healthcare Provider Details

I. General information

NPI: 1396193827
Provider Name (Legal Business Name): SHAWNA LISA REITER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2016
Last Update Date: 01/12/2024
Certification Date: 01/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 W BROADWAY STE D&E
FARMINGTON NM
87401-5638
US

IV. Provider business mailing address

4230 E TOWNE BLVD # 118
MADISON WI
53704-3704
US

V. Phone/Fax

Practice location:
  • Phone: 505-327-4796
  • Fax: 505-599-9351
Mailing address:
  • Phone: 715-523-9165
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number16362-132
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number9390-123
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number9390-123
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWB-2023-0044
License Number StateWI
# 5
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWB-2023-0044
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: