Basic Information
| Provider Information | |||||||||
| NPI: | 1629144043 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REED | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | OWEN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4860 ROBB ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | WHEAT RIDGE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800332184 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032787418 | ||||||||
| FaxNumber: | 8883415050 | ||||||||
| Practice Location | |||||||||
| Address1: | 220 W COLFAX AVE | ||||||||
| Address2: | STE 400 | ||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466011635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5748624511 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 03/15/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 20041292A | IN | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 20041292A | 01 | IN | PROFESSIONAL LICENSE | OTHER | 11629486 | 01 | IN | CAQH PIN | OTHER | 200262580 | 05 | IN | MEDICAID |