Provider Demographics
NPI:1114802493
Name:PETRY, REESE NICOLE
Entity type:Individual
Prefix:
First Name:REESE
Middle Name:NICOLE
Last Name:PETRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1049 E NEWELL ST
Mailing Address - Street 2:
Mailing Address - City:WHITE CLOUD
Mailing Address - State:MI
Mailing Address - Zip Code:49349-8795
Mailing Address - Country:US
Mailing Address - Phone:231-689-7330
Mailing Address - Fax:
Practice Address - Street 1:220 W PINE ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:MI
Practice Address - Zip Code:49412-1532
Practice Address - Country:US
Practice Address - Phone:231-760-9247
Practice Address - Fax:231-760-9247
Is Sole Proprietor?:No
Enumeration Date:2025-08-07
Last Update Date:2025-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician