Provider Demographics
NPI:1144785692
Name:REESE, KETURHA ANN
Entity Type:Individual
Prefix:MS
First Name:KETURHA
Middle Name:ANN
Last Name:REESE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11514 BELLAMAR ST
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33637-1933
Mailing Address - Country:US
Mailing Address - Phone:813-403-3906
Mailing Address - Fax:
Practice Address - Street 1:5104 COUNTRY SIDE DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33624-2013
Practice Address - Country:US
Practice Address - Phone:813-403-3906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-08
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No335E00000XSuppliersProsthetic/Orthotic Supplier