Provider Demographics
NPI:1245226075
Name:REILLY, THOMAS PETER (PHD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:PETER
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 1:92 ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-4525
Mailing Address - Country:US
Mailing Address - Phone:802-651-7533
Mailing Address - Fax:
Practice Address - Street 1:92 ADAMS ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-4525
Practice Address - Country:US
Practice Address - Phone:802-651-7533
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT048 0000298103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
966233OtherMVP
VT5432Medicaid