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General NPI Number Information
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NPI Number | 1649837857
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Entity Type | Individual
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Provider Name | DANIELLE MARIE REYSEN CCSH
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Gender | Female
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Dates
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Enumeration Date | 05/22/2019
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Last Update Date | 05/22/2019
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Provider Practice Location Address
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Address Line | 381 PALMER AVE
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City | GREEN LAKE
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State | WI
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Zip | 54941-9783
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Country | US
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Telephone | 920-572-0800
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Fax |
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Provider Business Mailing Address
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Address Line | 381 PALMER AVE
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City | GREEN LAKE
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State | WI
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Zip | 54941-9783
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Country | US
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Telephone | 920-572-0800
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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 | 204R00000X
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Taxonomy Name | Electrodiagnostic Medicine Physician
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License Number | 3348
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 247200000X
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Taxonomy Name | Other Technician
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License Number | 545
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License Number State | WI
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Taxonomy #3
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Taxonomy Code | 2472E0500X
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Taxonomy Name | EEG Technician
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License Number | 3348
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License Number State | WI
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Taxonomy #4
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Taxonomy Code | 174H00000X
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Taxonomy Name | Health Educator
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License Number | 111
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License Number State | WI
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