Provider Demographics
NPI:1487188348
Name:REILLY, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:REILLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1377 MOTOR PKWY
Mailing Address - Street 2:
Mailing Address - City:ISLANDIA
Mailing Address - State:NY
Mailing Address - Zip Code:11749-5249
Mailing Address - Country:US
Mailing Address - Phone:631-580-5200
Mailing Address - Fax:631-580-5222
Practice Address - Street 1:401 YOUNG AVE
Practice Address - Street 2:SUITE 255
Practice Address - City:MOORESTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08057-3130
Practice Address - Country:US
Practice Address - Phone:856-282-0336
Practice Address - Fax:856-234-3926
Is Sole Proprietor?:No
Enumeration Date:2017-04-18
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00169600225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist