Provider Demographics
NPI:1578233060
Name:SPADAFORA, REILLY
Entity Type:Individual
Prefix:
First Name:REILLY
Middle Name:
Last Name:SPADAFORA
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:PO BOX 631278
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-1278
Mailing Address - Country:US
Mailing Address - Phone:800-356-4049
Mailing Address - Fax:941-485-0519
Practice Address - Street 1:13121 ATLANTIC BLVD STE 200
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-0102
Practice Address - Country:US
Practice Address - Phone:904-491-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-15
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-250257106S00000X
FLRBT-21-176019106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician