Provider Demographics
NPI:1801480330
Name:RECKART, LORISSA
Entity type:Individual
Prefix:
First Name:LORISSA
Middle Name:
Last Name:RECKART
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 1:5061 DOGTOWN RD
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26537-8279
Mailing Address - Country:US
Mailing Address - Phone:304-435-4629
Mailing Address - Fax:
Practice Address - Street 1:5061 DOGTOWN RD
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:WV
Practice Address - Zip Code:26537-8279
Practice Address - Country:US
Practice Address - Phone:304-435-4629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-25
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker