Provider Demographics
NPI:1336530799
Name:REILLY, COURTNEY
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:REILLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 PARK AVE
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02910-2154
Mailing Address - Country:US
Mailing Address - Phone:401-270-9991
Mailing Address - Fax:401-270-2265
Practice Address - Street 1:626 PARK AVE
Practice Address - Street 2:SUITE 2A
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02910-2154
Practice Address - Country:US
Practice Address - Phone:401-270-9991
Practice Address - Fax:401-270-2265
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-06
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIOT01411225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist