Provider Demographics
NPI:1649837857
Name:REYSEN, DANIELLE MARIE (CCSH)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:MARIE
Last Name:REYSEN
Suffix:
Gender:F
Credentials:CCSH
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:MARIE
Other - Last Name:REYSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCSH
Mailing Address - Street 1:381 PALMER AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54941-9783
Mailing Address - Country:US
Mailing Address - Phone:920-572-0800
Mailing Address - Fax:
Practice Address - Street 1:381 PALMER AVE
Practice Address - Street 2:
Practice Address - City:GREEN LAKE
Practice Address - State:WI
Practice Address - Zip Code:54941-9783
Practice Address - Country:US
Practice Address - Phone:920-572-0800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-22
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3348204R00000X, 2472E0500X
WI545247200000X
WI111174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty
No204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic MedicineGroup - Multi-Specialty
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No2472E0500XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherEEG