Provider Demographics
NPI:1811307416
Name:REILLY, CARRIE (MED)
Entity type:Individual
Prefix:MRS
First Name:CARRIE
Middle Name:
Last Name:REILLY
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:THERESE
Other - Last Name:BAGARIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2155 MIRAMAR BLVD
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-3301
Mailing Address - Country:US
Mailing Address - Phone:216-320-5036
Mailing Address - Fax:
Practice Address - Street 1:2155 MIRAMAR BLVD
Practice Address - Street 2:
Practice Address - City:UNIVERSITY HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44118-3301
Practice Address - Country:US
Practice Address - Phone:216-320-5036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-05
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH1491906103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool