Provider Demographics
NPI:1306578224
Name:REA THERAPY
Entity type:Organization
Organization Name:REA THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BRUDNICKI
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:936-395-1051
Mailing Address - Street 1:5900 BALCONES DR STE 6698
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-4257
Mailing Address - Country:US
Mailing Address - Phone:936-220-1190
Mailing Address - Fax:
Practice Address - Street 1:5900 BALCONES DR STE 6698
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-4257
Practice Address - Country:US
Practice Address - Phone:936-220-1190
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-29
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149.024496OtherLCSW
WI9882-123OtherLCSW
TX107534OtherLCSW
WI19021-130OtherSAC-IT
VT089.0134724OtherLCSW