Healthcare Provider Details

I. General information

NPI: 1043048853
Provider Name (Legal Business Name): AMANDA JO REIMER SAC-IT, SWTC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2024
Last Update Date: 07/23/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 BROADWAY ST
BARABOO WI
53913-2183
US

IV. Provider business mailing address

505 BROADWAY ST
BARABOO WI
53913-2183
US

V. Phone/Fax

Practice location:
  • Phone: 608-355-4200
  • Fax: 608-355-4299
Mailing address:
  • Phone: 608-355-4200
  • Fax: 608-355-4299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number20618130
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: