Provider Demographics
NPI:1518588128
Name:HOLST REILLEY, CHARLOTTE ELIZABETH
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:ELIZABETH
Last Name:HOLST REILLEY
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 1:1915 N BAXTER DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85716-3326
Mailing Address - Country:US
Mailing Address - Phone:520-891-4619
Mailing Address - Fax:
Practice Address - Street 1:4110 W SWEETWATER DR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85745-9348
Practice Address - Country:US
Practice Address - Phone:520-743-0411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-05
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-17744101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional