Healthcare Provider Details

I. General information

NPI: 1770128712
Provider Name (Legal Business Name): KEITH J REILLEY PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2019
Last Update Date: 11/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 W READ ST UNIT B03
BALTIMORE MD
21201-4906
US

IV. Provider business mailing address

101 W READ ST UNIT B03
BALTIMORE MD
21201-4906
US

V. Phone/Fax

Practice location:
  • Phone: 610-733-0304
  • Fax:
Mailing address:
  • Phone: 610-733-0304
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberR210605
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: