Provider Demographics
NPI:1457488702
Name:REILLY, BURTON C (MA)
Entity Type:Individual
Prefix:
First Name:BURTON
Middle Name:C
Last Name:REILLY
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 MORGAN HWY
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18508
Mailing Address - Country:US
Mailing Address - Phone:570-207-7919
Mailing Address - Fax:570-962-1953
Practice Address - Street 1:475 MORGAN HWY
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18508
Practice Address - Country:US
Practice Address - Phone:570-207-7919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS005057L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist