Provider Demographics
NPI:1245409820
Name:REISKE, GLORIA MADELYN (LCSW)
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:MADELYN
Last Name:REISKE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 PLANTATION RD NE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24012-5713
Mailing Address - Country:US
Mailing Address - Phone:540-344-9501
Mailing Address - Fax:540-344-7162
Practice Address - Street 1:1304 PLANTATION RD NE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24012-5713
Practice Address - Country:US
Practice Address - Phone:540-344-7048
Practice Address - Fax:540-344-7162
Is Sole Proprietor?:No
Enumeration Date:2008-02-27
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040016951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical