Provider Demographics
NPI:1912375817
Name:REILLY, SEAN MICHAEL (LCSW)
Entity Type:Individual
Prefix:MR
First Name:SEAN
Middle Name:MICHAEL
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 1:1815 OLD 41 HWY NW
Mailing Address - Street 2:SUITE 110
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152
Mailing Address - Country:US
Mailing Address - Phone:678-468-9103
Mailing Address - Fax:
Practice Address - Street 1:1815 OLD 41 HWY NW
Practice Address - Street 2:SUITE 110
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152
Practice Address - Country:US
Practice Address - Phone:678-468-9103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-09
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLSW00000062351041C0700X
FLSW117491041C0700X
GACSW0067391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical