Provider Demographics
NPI:1912170598
Name:REILLY, NICOLE MARIE (MD, LMFT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:REILLY
Suffix:
Gender:F
Credentials:MD, LMFT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:WAKIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:19712 MACARTHUR BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-2407
Mailing Address - Country:US
Mailing Address - Phone:949-264-3325
Mailing Address - Fax:
Practice Address - Street 1:19712 MACARTHUR BLVD STE 110
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92612-2407
Practice Address - Country:US
Practice Address - Phone:949-264-3325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-04
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA98851207L00000X
CA127642106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology