Provider Demographics
NPI:1336657741
Name:USHER REEVES, RENEE
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:USHER REEVES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RENEE
Other - Middle Name:
Other - Last Name:USHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5163 ROSWELL RD
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-2206
Mailing Address - Country:US
Mailing Address - Phone:877-288-4760
Mailing Address - Fax:404-600-1259
Practice Address - Street 1:112 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263
Practice Address - Country:US
Practice Address - Phone:877-288-4760
Practice Address - Fax:404-600-1259
Is Sole Proprietor?:No
Enumeration Date:2018-01-19
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-21-48005103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA071423OtherCPH