Provider Demographics
NPI:1659844611
Name:REAGAN, BEN (PSYD)
Entity type:Individual
Prefix:DR
First Name:BEN
Middle Name:
Last Name:REAGAN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:927 MILKY WAY
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-4748
Mailing Address - Country:US
Mailing Address - Phone:630-777-8690
Mailing Address - Fax:
Practice Address - Street 1:1201 CUMBERLAND AVE
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-1359
Practice Address - Country:US
Practice Address - Phone:630-777-8690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-02
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20043159B103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical