1316238611 NPI number — KEVIN J. REILLY, PSY.D.,P.C.

Table of content: (NPI 1316238611)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316238611 NPI number — KEVIN J. REILLY, PSY.D.,P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KEVIN J. REILLY, PSY.D.,P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
NEUROBEHAVIORAL & REHABILITATION PSYCHOLOGY SERVICES
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316238611
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/04/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
601 EAST HAMPDEN AVENUE
Provider Second Line Business Mailing Address:
SUITE 420
Provider Business Mailing Address City Name:
ENGLEWOOD
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80113
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-523-3023
Provider Business Mailing Address Fax Number:
720-212-0344

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 E HAMPDEN AVE STE 420
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ENGLEWOOD
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80113-2770
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-523-3023
Provider Business Practice Location Address Fax Number:
303-523-3023
Provider Enumeration Date:
04/21/2011

Additional Information

Authorized Official

Authorized Official Last Name:
REILLY
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER/SOLE PROPRIETOR
Authorized Official Telephone Number:
303-523-3023

Provider Taxonomy Codes

  • Taxonomy code: 103G00000X , with the licence number:  1407 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 07014079 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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