Provider Demographics
NPI:1003614546
Name:REESE, MYA (DC)
Entity type:Individual
Prefix:
First Name:MYA
Middle Name:
Last Name:REESE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:800-326-2250
Mailing Address - Fax:262-857-5301
Practice Address - Street 1:12500 AURORA DR
Practice Address - Street 2:
Practice Address - City:PLEASANT PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53158-1227
Practice Address - Country:US
Practice Address - Phone:262-857-5300
Practice Address - Fax:262-857-5301
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-03
Last Update Date:2025-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH15393111N00000X
WI630112111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100327373Medicaid