Provider Demographics
NPI:1740097831
Name:REILLY, ANDREW KEVIN (AMFT, APCC)
Entity type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:KEVIN
Last Name:REILLY
Suffix:
Gender:M
Credentials:AMFT, APCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7733 HAMPTON AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90046-4778
Mailing Address - Country:US
Mailing Address - Phone:310-738-9565
Mailing Address - Fax:
Practice Address - Street 1:25000 AVENUE STANFORD STE 167
Practice Address - Street 2:
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-4596
Practice Address - Country:US
Practice Address - Phone:818-600-2034
Practice Address - Fax:661-667-4477
Is Sole Proprietor?:No
Enumeration Date:2024-12-12
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15446101YM0800X
CA143596106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health