Provider Demographics
NPI:1447582416
Name:REISER, MARK ANDREW (MS / LPC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANDREW
Last Name:REISER
Suffix:
Gender:M
Credentials:MS / LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 DOWNEY ST
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82072-1867
Mailing Address - Country:US
Mailing Address - Phone:307-399-3387
Mailing Address - Fax:
Practice Address - Street 1:1465 N 4TH ST
Practice Address - Street 2:SUITE 119
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82072-2066
Practice Address - Country:US
Practice Address - Phone:307-721-0700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-02
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLPC-1081101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional