Basic Information
| Provider Information | |||||||||
| NPI: | 1184868127 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REIGLE | ||||||||
| FirstName: | CATHLEEN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | AUD CCC-A | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRUECKNER | ||||||||
| OtherFirstName: | CATHLEEN | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | AUD CCC-A | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 99213 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761990213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6828853622 | ||||||||
| FaxNumber: | 6828853936 | ||||||||
| Practice Location | |||||||||
| Address1: | 1919 8TH AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761101358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6828854063 | ||||||||
| FaxNumber: | 6828851878 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2009 | ||||||||
| LastUpdateDate: | 01/05/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 535-156 | WI | N | Speech, Language and Hearing Service Providers | Audiologist | 231H00000X | 80547 | TX | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 324907002 | 05 | TX | MEDICAID | 324907003/HA1 | 05 | TX | MEDICAID | 324907001 | 05 | TX | MEDICAID | 324907004/HA1 CSN | 05 | TX | MEDICAID |