Healthcare Provider Details

I. General information

NPI: 1053476515
Provider Name (Legal Business Name): MARK WILLIAM REICH MS PSYCHOLOGY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 WEST COLLEGE AVENUE SUITE 815
APPLETON WI
54911
US

IV. Provider business mailing address

W2510 VALLEYWOOD LANE
APPLETON WI
54915
US

V. Phone/Fax

Practice location:
  • Phone: 920-733-1992
  • Fax: 920-733-1866
Mailing address:
  • Phone: 920-788-5261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2551123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: