Healthcare Provider Details

I. General information

NPI: 1700737863
Provider Name (Legal Business Name): MR. JOHN WIGMORE REILLY IV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2026
Last Update Date: 02/05/2026
Certification Date: 02/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2479 ALOMA AVE
WINTER PARK FL
32792-2541
US

IV. Provider business mailing address

1851 LPGA BLVD APT 11301
DAYTONA BEACH FL
32117-7192
US

V. Phone/Fax

Practice location:
  • Phone: 407-657-6692
  • Fax:
Mailing address:
  • Phone: 407-534-9317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: