Provider Demographics
NPI:1639395460
Name:REICHELT, TERA (LMFT)
Entity Type:Individual
Prefix:
First Name:TERA
Middle Name:
Last Name:REICHELT
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 ROBY RD
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:WI
Mailing Address - Zip Code:53589-1337
Mailing Address - Country:US
Mailing Address - Phone:608-220-8380
Mailing Address - Fax:
Practice Address - Street 1:619 RIVER ST STE F
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53508-9117
Practice Address - Country:US
Practice Address - Phone:608-424-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI707-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40995600Medicaid
WI707-124OtherMFT LICENSE NUMBER