Healthcare Provider Details

I. General information

NPI: 1669184149
Provider Name (Legal Business Name): LAUREN REILLY PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2022
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 BURNETTS WAY STE 230
SUFFOLK VA
23434-8168
US

IV. Provider business mailing address

PO BOX 412307
BOSTON MA
02241-2307
US

V. Phone/Fax

Practice location:
  • Phone: 757-942-2022
  • Fax: 757-512-8997
Mailing address:
  • Phone: 914-294-4050
  • Fax: 631-760-8306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number29240
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberCP055525T
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number14602
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.029235
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: