Provider Demographics
NPI:1932496866
Name:REILLY, DINAH SUE (PHD)
Entity Type:Individual
Prefix:MRS
First Name:DINAH
Middle Name:SUE
Last Name:REILLY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4048 S IRIONDO WAY
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-5784
Mailing Address - Country:US
Mailing Address - Phone:208-345-2657
Mailing Address - Fax:
Practice Address - Street 1:179 SW 5TH AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-2995
Practice Address - Country:US
Practice Address - Phone:208-367-8282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-29
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-474283XC2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283XC2000XHospitalsRehabilitation HospitalChildren