Provider Demographics
NPI:1326651894
Name:REESE, LAVERNE
Entity Type:Individual
Prefix:
First Name:LAVERNE
Middle Name:
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 1:150 S DURKIN DR UNIT 7
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-1191
Mailing Address - Country:US
Mailing Address - Phone:217-381-7406
Mailing Address - Fax:
Practice Address - Street 1:150 S DURKIN DR APT
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-1151
Practice Address - Country:US
Practice Address - Phone:217-381-7406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057003241224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant