Provider Demographics
NPI:1558810580
Name:MAUREEN LYONS REARDON, LLC
Entity Type:Organization
Organization Name:MAUREEN LYONS REARDON, LLC
Other - Org Name:M.L. REARDON, PH.D., ABPP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:LYONS
Authorized Official - Last Name:REARDON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, ABPP
Authorized Official - Phone:910-609-1990
Mailing Address - Street 1:5048 BARTONS ENCLAVE LN
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27613-8564
Mailing Address - Country:US
Mailing Address - Phone:919-800-1174
Mailing Address - Fax:
Practice Address - Street 1:2411 ROBESON ST
Practice Address - Street 2:SUITE 200
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28305-5576
Practice Address - Country:US
Practice Address - Phone:910-609-1990
Practice Address - Fax:910-609-1993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-03
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
NC3149103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensicGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC19K0BOtherBLUE CROSS BLUE SHIELD NC
NC19K0BOtherBLUE CROSS BLUE SHIELD NC