Provider Demographics
NPI:1326562463
Name:REILLY, KATHLEEN MARY (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARY
Last Name:REILLY
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8934 VICTORIA RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22151-1137
Mailing Address - Country:US
Mailing Address - Phone:703-978-1427
Mailing Address - Fax:
Practice Address - Street 1:6003 MASONDALE RD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22315-5596
Practice Address - Country:US
Practice Address - Phone:304-488-4372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-31
Last Update Date:2017-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202004340235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist