Provider Demographics
NPI:1447385737
Name:RELLER, LORIE J
Entity Type:Individual
Prefix:
First Name:LORIE
Middle Name:J
Last Name:RELLER
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 1:200 4TH AVE W
Mailing Address - Street 2:
Mailing Address - City:SHAKOPEE
Mailing Address - State:MN
Mailing Address - Zip Code:55379-1220
Mailing Address - Country:US
Mailing Address - Phone:952-496-8570
Mailing Address - Fax:952-496-8430
Practice Address - Street 1:200 4TH AVE W
Practice Address - Street 2:
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-1220
Practice Address - Country:US
Practice Address - Phone:952-496-8570
Practice Address - Fax:952-496-8430
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN069241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical