Provider Demographics
NPI:1710455472
Name:REILLY, COLLEEN LOUISE (MSW, LCSW, LCASA)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:LOUISE
Last Name:REILLY
Suffix:
Gender:F
Credentials:MSW, LCSW, LCASA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 W NC HIGHWAY 54
Mailing Address - Street 2:STE 103
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-5572
Mailing Address - Country:US
Mailing Address - Phone:919-354-0840
Mailing Address - Fax:919-748-4441
Practice Address - Street 1:3505 N ROXBORO ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-2767
Practice Address - Country:US
Practice Address - Phone:919-220-4224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-10
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-22966101YA0400X
NCC0118631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)