Provider Demographics
NPI:1699217356
Name:REILLY, JOSEPH (LCSW)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:REILLY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2955 MADISON AVE APT 12
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-2068
Mailing Address - Country:US
Mailing Address - Phone:203-560-0708
Mailing Address - Fax:
Practice Address - Street 1:2955 MADISON AVE APT 12
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-2068
Practice Address - Country:US
Practice Address - Phone:203-560-0708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-12
Last Update Date:2016-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT95181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical