Provider Demographics
NPI:1902806581
Name:REESMAN, PHYLLIS M (LCSW)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:M
Last Name:REESMAN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 N GARTH AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-4103
Mailing Address - Country:US
Mailing Address - Phone:573-443-2204
Mailing Address - Fax:573-875-5851
Practice Address - Street 1:15899 LOGANS LAKE RD
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:MO
Practice Address - Zip Code:65233-2866
Practice Address - Country:US
Practice Address - Phone:660-882-2333
Practice Address - Fax:550-882-2333
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000596101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1538204904OtherBOONVILLE NPI
MO3361OtherFEI I.D. NUMBER
MO5763918OtherFIRST HEALTH I.D. NUMBER
MO1649269622OtherGROUP BILLING NPI
MO203147OtherHEALTHLINK I.D. NUMBER
MO22157OtherBCBS I.D. NUMBER