Provider Demographics
NPI:1558901876
Name:REILLY, ALEXANDRA
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
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 1:2102 CAMBRIDGE BELTWAY DR STE E
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28273-4354
Mailing Address - Country:US
Mailing Address - Phone:704-799-6824
Mailing Address - Fax:704-799-6825
Practice Address - Street 1:2102 CAMBRIDGE BELTWAY DR STE E
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-4354
Practice Address - Country:US
Practice Address - Phone:704-799-6824
Practice Address - Fax:704-799-6825
Is Sole Proprietor?:No
Enumeration Date:2020-01-15
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
NCBACB563752103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician