Provider Demographics
NPI:1851442545
Name:BRENDA K OREILLY PHD PROFESSIONAL LLC
Entity Type:Organization
Organization Name:BRENDA K OREILLY PHD PROFESSIONAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:K
Authorized Official - Last Name:OREILLY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:970-613-4172
Mailing Address - Street 1:2629 REDWING RD
Mailing Address - Street 2:SUITE 316
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526
Mailing Address - Country:US
Mailing Address - Phone:970-613-4172
Mailing Address - Fax:970-223-1325
Practice Address - Street 1:2629 REDWING RD
Practice Address - Street 2:SUITE 316
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526
Practice Address - Country:US
Practice Address - Phone:970-613-4172
Practice Address - Fax:970-223-1325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2011-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1767103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO47036362Medicaid
CO47036362Medicaid