Provider Demographics
NPI:1942344817
Name:REILLY, JOHN THOMAS (MSW LCSW SACIT)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:THOMAS
Last Name:REILLY
Suffix:
Gender:M
Credentials:MSW LCSW SACIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3610 RURAL ST
Mailing Address - Street 2:APT #3
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1969 W HART RD
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511
Practice Address - Country:US
Practice Address - Phone:608-364-5686
Practice Address - Fax:608-363-5756
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI69311231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical