Provider Demographics
NPI:1356301295
Name:REILLY, CHARLES J (EDD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:J
Last Name:REILLY
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:158 UPLAND RD
Mailing Address - Street 2:
Mailing Address - City:WABAN
Mailing Address - State:MA
Mailing Address - Zip Code:02468-2005
Mailing Address - Country:US
Mailing Address - Phone:617-527-5561
Mailing Address - Fax:
Practice Address - Street 1:158 UPLAND RD
Practice Address - Street 2:
Practice Address - City:WABAN
Practice Address - State:MA
Practice Address - Zip Code:02468-2005
Practice Address - Country:US
Practice Address - Phone:617-527-5561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3037103TC0700X
103TF0200X, 103TA0400X
MA1608101YA0400X
MA958106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW03284Medicare ID - Type UnspecifiedPSYCHOLOGIST