Provider Demographics
NPI:1114178951
Name:REITZ, RANDALL SCOT (PHD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:SCOT
Last Name:REITZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 62
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81502-0062
Mailing Address - Country:US
Mailing Address - Phone:970-298-2800
Mailing Address - Fax:970-298-1809
Practice Address - Street 1:1160 PATTERSON RD
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81506-8275
Practice Address - Country:US
Practice Address - Phone:970-298-2800
Practice Address - Fax:970-298-6902
Is Sole Proprietor?:No
Enumeration Date:2008-10-09
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMFT629106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COMFT629OtherLMFT
CO30179041Medicaid