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General NPI Number Information
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NPI Number | 1295165280
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Entity Type | Individual
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Provider Name | MARY BETH REYNOSO
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Gender | Female
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Dates
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Enumeration Date | 11/12/2013
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Last Update Date | 08/14/2023
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Provider Practice Location Address
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Address Line | 2906 S 20TH ST
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City | MILWAUKEE
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State | WI
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Zip | 53215-3732
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Country | US
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Telephone | 920-905-2865
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 778789
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City | CHICAGO
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State | IL
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Zip | 60677-8789
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Country | US
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Telephone | 414-672-1353
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 8410-123
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License Number State | WI
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