Provider Demographics
NPI:1457126211
Name:REILLY, RYAN PATRICK (AMFT)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:PATRICK
Last Name:REILLY
Suffix:
Gender:M
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 N KENTER AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-2336
Mailing Address - Country:US
Mailing Address - Phone:630-253-5066
Mailing Address - Fax:
Practice Address - Street 1:360 N KENTER AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-2336
Practice Address - Country:US
Practice Address - Phone:630-253-5066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-21
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA142925106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist