Provider Demographics
NPI:1881718864
Name:REILLY, KATHRYN MILLER (PHD)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:MILLER
Last Name:REILLY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:44242 ARLINGTON RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-2144
Mailing Address - Country:US
Mailing Address - Phone:734-516-7424
Mailing Address - Fax:
Practice Address - Street 1:19855 OUTER DR
Practice Address - Street 2:103B-W
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2022
Practice Address - Country:US
Practice Address - Phone:313-359-1977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008955103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI11283769OtherCAQH ID
MI38-3304817OtherTAX ID
MI680H247650OtherBCBS PIN
MI11283769OtherCAQH ID