Provider Demographics
NPI:1689400210
Name:REISENER, LAURIE RAE (LPC-IT)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:RAE
Last Name:REISENER
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3703 N MURRAY AVE
Mailing Address - Street 2:
Mailing Address - City:SHOREWOOD
Mailing Address - State:WI
Mailing Address - Zip Code:53211-2554
Mailing Address - Country:US
Mailing Address - Phone:414-698-7776
Mailing Address - Fax:
Practice Address - Street 1:3703 N MURRAY AVE
Practice Address - Street 2:
Practice Address - City:SHOREWOOD
Practice Address - State:WI
Practice Address - Zip Code:53211-2554
Practice Address - Country:US
Practice Address - Phone:414-698-7776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-10
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8106-226101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional