=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760913362
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEATHER A. REARDON LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2017
-----------------------------------------------------
Last Update Date | 03/24/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 BANK AVE
-----------------------------------------------------
City | KAUKAUNA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54130-2581
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-470-8359
-----------------------------------------------------
Fax | 920-843-9381
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 BANK AVE
-----------------------------------------------------
City | KAUKAUNA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54130-2581
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-470-8359
-----------------------------------------------------
Fax | 920-843-9381
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COUNSELOR
-----------------------------------------------------
Name | MRS. HEATHER ANNE REARDON-NABBEFELD
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 920-470-8359
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 6018-125
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------