Provider Demographics
NPI:1376146126
Name:REILLY, SEAN PATRICK (PLMFT)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:PATRICK
Last Name:REILLY
Suffix:
Gender:M
Credentials:PLMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3634 WYOMING ST # 2F
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63116-4835
Mailing Address - Country:US
Mailing Address - Phone:314-600-7939
Mailing Address - Fax:
Practice Address - Street 1:330 N GORE AVE
Practice Address - Street 2:
Practice Address - City:WEBSTER GROVES
Practice Address - State:MO
Practice Address - Zip Code:63119-1600
Practice Address - Country:US
Practice Address - Phone:314-600-7939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020033676101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health