Provider Demographics
NPI:1629559927
Name:REILLY, PATRICK MORAN (LMSW)
Entity Type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:MORAN
Last Name:REILLY
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3954 ANGLIA CT
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48323-1800
Mailing Address - Country:US
Mailing Address - Phone:248-701-4686
Mailing Address - Fax:
Practice Address - Street 1:1601 JOSLYN RD
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48360-1139
Practice Address - Country:US
Practice Address - Phone:248-701-4686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-24
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801102317104100000X
MI68011144091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker