Healthcare Provider Details

I. General information

NPI: 1932496866
Provider Name (Legal Business Name): DINAH SUE REILLY PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2011
Last Update Date: 06/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

179 SW 5TH AVE
MERIDIAN ID
83642-2995
US

IV. Provider business mailing address

4048 S IRIONDO WAY
BOISE ID
83706-5784
US

V. Phone/Fax

Practice location:
  • Phone: 208-367-8282
  • Fax:
Mailing address:
  • Phone: 208-345-2657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283XC2000X
TaxonomyChildren's Rehabilitation Hospital
License NumberPT-474
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: