Provider Demographics
NPI:1942321450
Name:REILLY, STEVEN J (MA)
Entity Type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:J
Last Name:REILLY
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 STATE ST FL 14
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16501-1814
Mailing Address - Country:US
Mailing Address - Phone:814-459-6858
Mailing Address - Fax:888-424-8341
Practice Address - Street 1:1001 STATE ST FL 14
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16501-1814
Practice Address - Country:US
Practice Address - Phone:814-459-6858
Practice Address - Fax:888-424-8341
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS-006836-L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPS-006836-LOtherPSYCHOLOGIST