Provider Demographics
NPI:1801458468
Name:REINKE, LORI ANN
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:ANN
Last Name:REINKE
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 1:2614 W 1300 S
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:UT
Mailing Address - Zip Code:84075-8301
Mailing Address - Country:US
Mailing Address - Phone:480-215-8337
Mailing Address - Fax:
Practice Address - Street 1:3280 W 3500 S STE E
Practice Address - Street 2:
Practice Address - City:WEST VALLEY
Practice Address - State:UT
Practice Address - Zip Code:84119-2668
Practice Address - Country:US
Practice Address - Phone:801-979-1351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-03
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10694584-3904106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist