Provider Demographics
NPI:1689343121
Name:REILLY, BRIAN J
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:J
Last Name:REILLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 PARKMOOR AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-2407
Mailing Address - Country:US
Mailing Address - Phone:408-284-2850
Mailing Address - Fax:408-284-0400
Practice Address - Street 1:1555 PARKMOOR AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-2407
Practice Address - Country:US
Practice Address - Phone:408-284-2850
Practice Address - Fax:408-284-0400
Is Sole Proprietor?:No
Enumeration Date:2021-09-08
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAACSW104543101Y00000X
CA1045431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor