Basic Information
| Provider Information | |||||||||
| NPI: | 1528627684 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REISEN | ||||||||
| FirstName: | EMILIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | HICKS | ||||||||
| OtherFirstName: | EMILIE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 5285 | ||||||||
| Address2: | |||||||||
| City: | GRAND ISLAND | ||||||||
| State: | NE | ||||||||
| PostalCode: | 688025285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3086751853 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3004 W FAIDLEY AVE | ||||||||
| Address2: | |||||||||
| City: | GRAND ISLAND | ||||||||
| State: | NE | ||||||||
| PostalCode: | 688034109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3083985170 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2019 | ||||||||
| LastUpdateDate: | 06/20/2019 | ||||||||
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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 | 225100000X | 3960 | NE | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.