Provider Demographics
NPI:1457306060
Name:REID, JOHN RAEBURN (PHD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RAEBURN
Last Name:REID
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 KS HWY 264
Mailing Address - Street 2:
Mailing Address - City:LARNED
Mailing Address - State:KS
Mailing Address - Zip Code:67550-5353
Mailing Address - Country:US
Mailing Address - Phone:620-285-4065
Mailing Address - Fax:620-285-4249
Practice Address - Street 1:1301 KS HWY 264
Practice Address - Street 2:
Practice Address - City:LARNED
Practice Address - State:KS
Practice Address - Zip Code:67550-5353
Practice Address - Country:US
Practice Address - Phone:620-285-4065
Practice Address - Fax:620-285-4249
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLP1322103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P81056Medicare UPIN
KS119759Medicare ID - Type Unspecified