Provider Demographics
NPI:1417044256
Name:REILLY, KATHLEEN (LCSW)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:REILLY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3551 WARICK DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75229-6007
Mailing Address - Country:US
Mailing Address - Phone:646-724-5151
Mailing Address - Fax:
Practice Address - Street 1:1380 RIVER BEND DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75247-4914
Practice Address - Country:US
Practice Address - Phone:214-743-6159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0705011041C0700X
TX560661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH4211Medicare ID - Type Unspecified
P13717Medicare UPIN