Healthcare Provider Details

I. General information

NPI: 1558810580
Provider Name (Legal Business Name): MAUREEN LYONS REARDON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2016
Last Update Date: 10/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2411 ROBESON ST SUITE 200
FAYETTEVILLE NC
28305-5576
US

IV. Provider business mailing address

5048 BARTONS ENCLAVE LN
RALEIGH NC
27613-8564
US

V. Phone/Fax

Practice location:
  • Phone: 910-609-1990
  • Fax: 910-609-1993
Mailing address:
  • Phone: 919-800-1174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number3149
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. MAUREEN LYONS REARDON
Title or Position: OWNER
Credential: PH.D., ABPP
Phone: 910-609-1990