Healthcare Provider Details

I. General information

NPI: 1619462942
Provider Name (Legal Business Name): EMILY RENEE REARDON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2018
Last Update Date: 07/26/2021
Certification Date: 07/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 US 70 HWY E STE 201
GARNER NC
27529-3982
US

IV. Provider business mailing address

2808 BARWELL RD
RALEIGH NC
27610-5427
US

V. Phone/Fax

Practice location:
  • Phone: 919-791-5611
  • Fax: 919-800-3050
Mailing address:
  • Phone: 608-417-8144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC013842
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number18013-130
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: