Provider Demographics
NPI:1780979351
Name:REAKTENWALT, EHRICA D
Entity type:Individual
Prefix:MRS
First Name:EHRICA
Middle Name:D
Last Name:REAKTENWALT
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 1:206 S MAIN ST
Mailing Address - Street 2:BOX 596
Mailing Address - City:MACKINAW
Mailing Address - State:IL
Mailing Address - Zip Code:61755-7511
Mailing Address - Country:US
Mailing Address - Phone:309-258-1601
Mailing Address - Fax:
Practice Address - Street 1:206 S MAIN ST
Practice Address - Street 2:BOX 596
Practice Address - City:MACKINAW
Practice Address - State:IL
Practice Address - Zip Code:61755-7511
Practice Address - Country:US
Practice Address - Phone:309-258-1601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-12
Last Update Date:2011-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency