Provider Demographics
NPI:1053861468
Name:REILLY, PATRICK O'NEILL (SAC-IT)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:O'NEILL
Last Name:REILLY
Suffix:
Gender:M
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19115 W CAPITOL DR STE 117
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-2754
Mailing Address - Country:US
Mailing Address - Phone:262-781-0240
Mailing Address - Fax:262-373-0148
Practice Address - Street 1:19115 W CAPITOL DR STE 117
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-2754
Practice Address - Country:US
Practice Address - Phone:262-781-0240
Practice Address - Fax:262-373-0148
Is Sole Proprietor?:No
Enumeration Date:2016-10-10
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17732-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)