Provider Demographics
NPI:1700864659
Name:REILLY, PATRICIA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:
Last Name:REILLY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 FOUNTAINHEAD LN
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28301-5462
Mailing Address - Country:US
Mailing Address - Phone:910-485-7005
Mailing Address - Fax:910-495-8629
Practice Address - Street 1:103 FOUNTAINHEAD LN
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-5462
Practice Address - Country:US
Practice Address - Phone:910-485-7005
Practice Address - Fax:910-495-8629
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC000463101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC70929OtherBLUECROSS/BLUESHIELD
NC2861091Medicare ID - Type Unspecified