Provider Demographics
NPI:1003207218
Name:REILLY, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:REILLY
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 1:1100 SE FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-3823
Mailing Address - Country:US
Mailing Address - Phone:772-320-0770
Mailing Address - Fax:772-320-0181
Practice Address - Street 1:1100 SE FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-3823
Practice Address - Country:US
Practice Address - Phone:772-320-0770
Practice Address - Fax:772-320-0181
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-10
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL912987100Medicaid