Healthcare Provider Details

I. General information

NPI: 1205859824
Provider Name (Legal Business Name): MARY KATHRYN REEVES LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 10/05/2023
Certification Date: 10/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

461 DUBOIS RD
OWEGO NY
13827-2403
US

IV. Provider business mailing address

461 DUBOIS RD
OWEGO NY
13827-2403
US

V. Phone/Fax

Practice location:
  • Phone: 607-744-1100
  • Fax:
Mailing address:
  • Phone: 607-744-1100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0701003804
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: