Provider Demographics
NPI:1750650180
Name:REILLY, BLANCA ESMERALDA (MS SLP)
Entity Type:Individual
Prefix:MRS
First Name:BLANCA
Middle Name:ESMERALDA
Last Name:REILLY
Suffix:
Gender:F
Credentials:MS SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 PECONIC ST APT 288A
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-7162
Mailing Address - Country:US
Mailing Address - Phone:917-363-7351
Mailing Address - Fax:
Practice Address - Street 1:500 PECONIC ST APT 288A
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-7162
Practice Address - Country:US
Practice Address - Phone:917-363-7351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-13
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0214761235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist