Provider Demographics
NPI:1104380997
Name:REID, BRIAN LEIGH
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:LEIGH
Last Name:REID
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:727 N HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-2227
Mailing Address - Country:US
Mailing Address - Phone:618-533-1891
Mailing Address - Fax:
Practice Address - Street 1:727 N HICKORY ST
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-2227
Practice Address - Country:US
Practice Address - Phone:618-533-1891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-25
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool