Provider Demographics
NPI:1821360413
Name:REID, MARY ELLEN
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELLEN
Last Name:REID
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 1:203 S WATER ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LOUISA
Mailing Address - State:KY
Mailing Address - Zip Code:41230-1347
Mailing Address - Country:US
Mailing Address - Phone:606-638-0222
Mailing Address - Fax:606-638-0222
Practice Address - Street 1:203 S WATER ST
Practice Address - Street 2:SUITE 101
Practice Address - City:LOUISA
Practice Address - State:KY
Practice Address - Zip Code:41230-1347
Practice Address - Country:US
Practice Address - Phone:606-638-0222
Practice Address - Fax:606-638-0222
Is Sole Proprietor?:No
Enumeration Date:2012-01-30
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL15293101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral