Healthcare Provider Details

I. General information

NPI: 1063074912
Provider Name (Legal Business Name): CHRISTOPHER REILLY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2019
Last Update Date: 05/27/2022
Certification Date: 04/22/2022
Deactivation Date: 03/14/2022
Reactivation Date: 03/29/2022

III. Provider practice location address

2400 MOORPARK AVE STE 300
SAN JOSE CA
95128-2680
US

IV. Provider business mailing address

2400 MOORPARK AVE STE 300
SAN JOSE CA
95128-2680
US

V. Phone/Fax

Practice location:
  • Phone: 408-975-2730
  • Fax:
Mailing address:
  • Phone: 408-975-2730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberC059990419
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberB00001760521
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: