Provider Demographics
NPI:1619462942
Name:REARDON, EMILY RENEE
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:RENEE
Last Name:REARDON
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 1:2808 BARWELL RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-5427
Mailing Address - Country:US
Mailing Address - Phone:608-417-8144
Mailing Address - Fax:
Practice Address - Street 1:136 US 70 HWY E STE 201
Practice Address - Street 2:
Practice Address - City:GARNER
Practice Address - State:NC
Practice Address - Zip Code:27529-3982
Practice Address - Country:US
Practice Address - Phone:919-791-5611
Practice Address - Fax:919-800-3050
Is Sole Proprietor?:No
Enumeration Date:2018-06-28
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0138421041C0700X
WI18013-130101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical