Provider Demographics
NPI:1700598604
Name:REILLY, ELIZABETH WYNNE (PT, ATP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:WYNNE
Last Name:REILLY
Suffix:
Gender:F
Credentials:PT, ATP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6369 MCCALLUM ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144-2551
Mailing Address - Country:US
Mailing Address - Phone:215-901-6862
Mailing Address - Fax:
Practice Address - Street 1:6369 MCCALLUM ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19144-2551
Practice Address - Country:US
Practice Address - Phone:215-901-6862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-22
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT003098E225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist