Basic Information
| Provider Information | |||||||||
| NPI: | 1316955669 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REITHER | ||||||||
| FirstName: | SHELLEY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | LCPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 E CARPENTER ST | ||||||||
| Address2: | PO BOX 1977 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627025324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175446464 | ||||||||
| FaxNumber: | 2177576021 | ||||||||
| Practice Location | |||||||||
| Address1: | 557 N WESTGATE AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 626501156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172457275 | ||||||||
| FaxNumber: | 2172457427 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | IL | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 681484 | 01 | IL | HEALTHLINK | OTHER | 06932018 | 01 | IL | BC/BS | OTHER | 109119 | 01 | IL | HEALTH ALLIANCE | OTHER |