Provider Demographics
NPI:1578222014
Name:BARTH, REANNA
Entity Type:Individual
Prefix:
First Name:REANNA
Middle Name:
Last Name:BARTH
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 1:620 DAKOTA ST
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60012-3732
Mailing Address - Country:US
Mailing Address - Phone:810-347-4745
Mailing Address - Fax:
Practice Address - Street 1:620 DAKOTA ST
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60012-3732
Practice Address - Country:US
Practice Address - Phone:810-347-4745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-13
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.017685101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health