MEDICARE: REEGAN COUNTRYMAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician	RBT-26-518368	IL

General Provider Information

NPI Number	:	1295680684
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REEGAN COUNTRYMAN

Provider Business Mailing Address
First Line	:	711 OFALLON TROY RD
Second Line	:
City	:	LEBANON
State	:	IL
Zip	:	62254-1827
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2421 CORPORATE CTR STE 100
Second Line	:
City	:	GRANITE CITY
State	:	IL
Zip	:	62040-4195
Country	:	US
Telephone Number	:	618-589-5165
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/02/2026
Last Update Date	:	03/02/2026

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Directions to “ REEGAN COUNTRYMAN ” Practice Location

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