Healthcare Provider Details

I. General information

NPI: 1972680668
Provider Name (Legal Business Name): RICHARD DEAN REILLY LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 12/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10400 RIDGLAND RD STE 1
COCKEYSVILLE MD
21030-2715
US

IV. Provider business mailing address

10400 RIDGLAND RD STE 1
COCKEYSVILLE MD
21030-2715
US

V. Phone/Fax

Practice location:
  • Phone: 410-628-6120
  • Fax: 410-628-0953
Mailing address:
  • Phone: 410-628-6120
  • Fax: 410-628-9825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC2216
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: