Provider Demographics
NPI:1578012373
Name:O'REILLY, EDWARD J (LICDC-CS)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:J
Last Name:O'REILLY
Suffix:
Gender:M
Credentials:LICDC-CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:899 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43205-1156
Mailing Address - Country:US
Mailing Address - Phone:614-220-8655
Mailing Address - Fax:614-220-8658
Practice Address - Street 1:1115 S HAMILTON RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43227-1311
Practice Address - Country:US
Practice Address - Phone:380-201-1110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-22
Last Update Date:2024-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLICDC.933651101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH933651OtherOHIO CHEMICAL DEPENDENCY PROFESSIONALS BOARD