Provider Demographics
NPI:1124185624
Name:REILLY, RICHARD A (PHD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:A
Last Name:REILLY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 CONCORD AVE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138
Mailing Address - Country:US
Mailing Address - Phone:617-864-1966
Mailing Address - Fax:
Practice Address - Street 1:227 CONCORD AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138
Practice Address - Country:US
Practice Address - Phone:617-864-1966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4167103T00000X, 103TC0700X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW04110OtherBCBS
MA0524182Medicaid
MA0524182Medicaid