Provider Demographics
NPI:1326316886
Name:REILLY, THOMAS (LADC, LPC)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:REILLY
Suffix:
Gender:M
Credentials:LADC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 HAZEL TER STE 11
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:CT
Mailing Address - Zip Code:06525-2240
Mailing Address - Country:US
Mailing Address - Phone:203-819-7650
Mailing Address - Fax:203-298-9487
Practice Address - Street 1:30 HAZEL TERRACE
Practice Address - Street 2:SUITE 11
Practice Address - City:WOODBRIDGE
Practice Address - State:CT
Practice Address - Zip Code:06525-2209
Practice Address - Country:US
Practice Address - Phone:203-819-7650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-12
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002448101YM0800X
CT000951101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008024427Medicaid
CT008023170Medicaid
CT008042339Medicaid
CT008038188Medicaid