Provider Demographics
NPI:1073195517
Name:REIDY, MARY CATHERINE (LPC)
Entity Type:Individual
Prefix:
First Name:MARY CATHERINE
Middle Name:
Last Name:REIDY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 ELM AVE SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24016-4001
Mailing Address - Country:US
Mailing Address - Phone:540-981-9351
Mailing Address - Fax:
Practice Address - Street 1:611 MCDOWELL AVE NW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-1225
Practice Address - Country:US
Practice Address - Phone:540-981-9351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-23
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1437137734Medicaid