Provider Demographics
NPI:1881604106
Name:REILLY, CHRISTINE (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:REILLY
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1477 HYDE PARK DR
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-8145
Mailing Address - Country:US
Mailing Address - Phone:407-760-8988
Mailing Address - Fax:
Practice Address - Street 1:3590 N US HIGHWAY 17/92
Practice Address - Street 2:SUITE 1038
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-4510
Practice Address - Country:US
Practice Address - Phone:407-322-6222
Practice Address - Fax:407-322-5596
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 8666235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL8989997 00Medicaid
FLSA 8666OtherSPEECH LANGUAGE PATHOLOGY