=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003614546
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MYA REESE DC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2025
-----------------------------------------------------
Last Update Date | 08/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12500 AURORA DR
-----------------------------------------------------
City | PLEASANT PRAIRIE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53158-1227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-857-5300
-----------------------------------------------------
Fax | 262-857-5301
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 735044
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60673-5044
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-326-2250
-----------------------------------------------------
Fax | 262-857-5301
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH15393
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 630112
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------