Provider Demographics
NPI:1922315878
Name:REILLY, LISA JILL (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:JILL
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 1:7 RIUNITE RD
Mailing Address - Street 2:
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-2663
Mailing Address - Country:US
Mailing Address - Phone:631-246-5020
Mailing Address - Fax:631-476-9322
Practice Address - Street 1:118 SPRING ST
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1817
Practice Address - Country:US
Practice Address - Phone:631-476-0564
Practice Address - Fax:631-476-9322
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-13
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0720211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical