Basic Information
Provider Information | |||||||||
NPI: | 1467473447 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | REETZ | ||||||||
FirstName: | MARLYS | ||||||||
MiddleName: | JOANN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PH.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ELDRIDGE | ||||||||
OtherFirstName: | MARLYS | ||||||||
OtherMiddleName: | REETZ | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PH.D. | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 970 W WOOSTER ST | ||||||||
Address2: | SUITE 124 | ||||||||
City: | BOWLING GREEN | ||||||||
State: | OH | ||||||||
PostalCode: | 434022643 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4193526666 | ||||||||
FaxNumber: | 4193531117 | ||||||||
Practice Location | |||||||||
Address1: | 970 W WOOSTER ST | ||||||||
Address2: | SUITE 124 | ||||||||
City: | BOWLING GREEN | ||||||||
State: | OH | ||||||||
PostalCode: | 434022643 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4193526666 | ||||||||
FaxNumber: | 4193531117 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/22/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 3434 | OH | Y |   | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.