Provider Demographics
NPI:1427208057
Name:REAVES, VENODIA (OTR)
Entity Type:Individual
Prefix:MRS
First Name:VENODIA
Middle Name:
Last Name:REAVES
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9321 N 85TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53224-1310
Mailing Address - Country:US
Mailing Address - Phone:414-354-7094
Mailing Address - Fax:
Practice Address - Street 1:2409 N 36TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-3040
Practice Address - Country:US
Practice Address - Phone:414-875-8892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-18
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI206-026171M00000X, 172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker