Provider Demographics
NPI:1396193827
Name:REITER, SHAWNA LISA (LCSW)
Entity type:Individual
Prefix:
First Name:SHAWNA
Middle Name:LISA
Last Name:REITER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4230 E TOWNE BLVD # 118
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-3704
Mailing Address - Country:US
Mailing Address - Phone:715-523-9165
Mailing Address - Fax:
Practice Address - Street 1:1001 W BROADWAY STE D&E
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5638
Practice Address - Country:US
Practice Address - Phone:505-327-4796
Practice Address - Fax:505-599-9351
Is Sole Proprietor?:No
Enumeration Date:2016-05-25
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16362-132101YA0400X
WI9390-123101YA0400X, 102L00000X
WISWB-2023-00441041C0700X
NMSWB-2023-00441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
9390-123OtherLCSW