Provider Demographics
NPI:1275712481
Name:REILLY, BLAINE COLIN (LCPC)
Entity Type:Individual
Prefix:MR
First Name:BLAINE
Middle Name:COLIN
Last Name:REILLY
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4048 S IRIONDO WAY
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-5784
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2971 E COPPER POINT DR STE 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-9276
Practice Address - Country:US
Practice Address - Phone:208-376-5683
Practice Address - Fax:208-376-5690
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-24
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID4470101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health