Provider Demographics
NPI:1487999207
Name:BIRT, REGINALD T (LCSW)
Entity type:Individual
Prefix:
First Name:REGINALD
Middle Name:T
Last Name:BIRT
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 1:4868 N 89TH ST
Mailing Address - Street 2:BIRT SUPPORTIVE SERVICES LLC
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53225-4106
Mailing Address - Country:US
Mailing Address - Phone:414-522-6800
Mailing Address - Fax:414-240-8497
Practice Address - Street 1:6815 W CAPITOL DR STE 105
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-2056
Practice Address - Country:US
Practice Address - Phone:414-522-6800
Practice Address - Fax:414-240-8497
Is Sole Proprietor?:No
Enumeration Date:2012-12-05
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
WI126882-121104100000X
WI8520-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1487999207Medicaid