Provider Demographics
NPI:1619103231
Name:REESE, ROBERT WILLIAM (MA, TLLP)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:WILLIAM
Last Name:REESE
Suffix:
Gender:M
Credentials:MA, TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28000 DEQUINDRE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-2468
Mailing Address - Country:US
Mailing Address - Phone:586-753-0405
Mailing Address - Fax:586-753-0404
Practice Address - Street 1:5111 AUTO CLUB DR
Practice Address - Street 2:# 120
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2749
Practice Address - Country:US
Practice Address - Phone:313-583-0735
Practice Address - Fax:313-583-0751
Is Sole Proprietor?:No
Enumeration Date:2009-06-10
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013873103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist