Provider Demographics
NPI:1740019884
Name:REILLY, ELLEN
Entity type:Individual
Prefix:
First Name:ELLEN
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 1:1650 S 70TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506-1569
Mailing Address - Country:US
Mailing Address - Phone:402-413-9583
Mailing Address - Fax:
Practice Address - Street 1:1650 S 70TH ST STE 100
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-1569
Practice Address - Country:US
Practice Address - Phone:402-413-9583
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE13876101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health