Basic Information
Provider Information | |||||||||
NPI: | 1558731919 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | REESE | ||||||||
FirstName: | MATTHEW | ||||||||
MiddleName: | P | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2637 EDENBORN AVE STE 302 | ||||||||
Address2: |   | ||||||||
City: | METAIRIE | ||||||||
State: | LA | ||||||||
PostalCode: | 700027042 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5045793811 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3616 S I 10 SERVICE RD W STE 100 | ||||||||
Address2: |   | ||||||||
City: | METAIRIE | ||||||||
State: | LA | ||||||||
PostalCode: | 700011884 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5048385257 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/29/2015 | ||||||||
LastUpdateDate: | 09/20/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/20/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WC0400X | 149101 | LA | N |   | Nursing Service Providers | Registered Nurse | Case Management | 171M00000X |   |   | N |   | Other Service Providers | Case Manager/Care Coordinator |   | 363LP0808X | 226873 | LA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.