Provider Demographics
NPI:1952034597
Name:REESE, KEVIN W (PHD, PAS INHC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:W
Last Name:REESE
Suffix:
Gender:M
Credentials:PHD, PAS INHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 FITZGERALD DR.
Mailing Address - Street 2:
Mailing Address - City:E. HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06118
Mailing Address - Country:US
Mailing Address - Phone:860-794-5625
Mailing Address - Fax:
Practice Address - Street 1:61 FITZGERALD DR.
Practice Address - Street 2:
Practice Address - City:E. HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06118
Practice Address - Country:US
Practice Address - Phone:860-794-5625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-01
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education