Basic Information
| Provider Information | |||||||||
| NPI: | 1467088559 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | REED | ||||||||
| MiddleName: | |||||||||
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| Credential: | HIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 131 CARMICHAEL RD STE 204 | ||||||||
| Address2: | |||||||||
| City: | HUDSON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540168271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153811330 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 131 CARMICHAEL RD STE 204 | ||||||||
| Address2: | |||||||||
| City: | HUDSON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540168271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153811330 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2020 | ||||||||
| LastUpdateDate: | 03/20/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | 1618-60 | WI | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
ID Information
| ID | Type | State | Issuer | Description | 1618-60 | 05 | WI | MEDICAID |