Provider Demographics
NPI:1548706369
Name:REICHARD, REBECCA ANN
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANN
Last Name:REICHARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:ANN
Other - Last Name:REICHARD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICSW
Mailing Address - Street 1:215 MILKY WAY STREET SOUTH
Mailing Address - Street 2:
Mailing Address - City:COSMOS
Mailing Address - State:MN
Mailing Address - Zip Code:56288
Mailing Address - Country:US
Mailing Address - Phone:320-877-7220
Mailing Address - Fax:320-877-7479
Practice Address - Street 1:215 MILKY WAY STREET SOUTH
Practice Address - Street 2:
Practice Address - City:COSMOS
Practice Address - State:MN
Practice Address - Zip Code:56288
Practice Address - Country:US
Practice Address - Phone:320-877-7220
Practice Address - Fax:320-877-7479
Is Sole Proprietor?:No
Enumeration Date:2017-01-18
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN21409101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional