Provider Demographics
NPI:1871692772
Name:REISNER, ANDREW DOUGLAS (PSY D)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:DOUGLAS
Last Name:REISNER
Suffix:
Gender:M
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66737 OLD TWENTY ONE RD
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:OH
Mailing Address - Zip Code:43725-8987
Mailing Address - Country:US
Mailing Address - Phone:740-439-1371
Mailing Address - Fax:740-432-1954
Practice Address - Street 1:66737 OLD TWENTY ONE RD
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:OH
Practice Address - Zip Code:43725-8987
Practice Address - Country:US
Practice Address - Phone:740-439-1371
Practice Address - Fax:740-432-1954
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4109103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHRECP01403Medicare ID - Type Unspecified