Provider Demographics
NPI:1639684798
Name:REANO, MICHAEL DEAN
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DEAN
Last Name:REANO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3005 NW 14TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73107-4710
Mailing Address - Country:US
Mailing Address - Phone:830-309-9805
Mailing Address - Fax:
Practice Address - Street 1:3005 NW 14TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73107-4710
Practice Address - Country:US
Practice Address - Phone:830-309-9805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-11
Last Update Date:2022-10-19
Deactivation Date:2022-07-16
Deactivation Code:
Reactivation Date:2022-09-01
Provider Licenses
StateLicense IDTaxonomies
OK0000000101YA0400X
175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)