Provider Demographics
NPI:1376614586
Name:REESE, SANDRA C (PHD)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:C
Last Name:REESE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1243 WILLOW POND DR
Mailing Address - Street 2:
Mailing Address - City:WAITE PARK
Mailing Address - State:MN
Mailing Address - Zip Code:56387-2038
Mailing Address - Country:US
Mailing Address - Phone:320-230-7357
Mailing Address - Fax:
Practice Address - Street 1:2025 STEARNS WAY
Practice Address - Street 2:SUITE 111
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-4491
Practice Address - Country:US
Practice Address - Phone:320-253-3540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 1840103G00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN57196REOtherBLUE CROSS
680001154Medicare ID - Type Unspecified