Healthcare Provider Details

I. General information

NPI: 1245226075
Provider Name (Legal Business Name): THOMAS PETER REILLY PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/27/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 ADAMS ST
BURLINGTON VT
05401-4525
US

IV. Provider business mailing address

92 ADAMS ST
BURLINGTON VT
05401-4525
US

V. Phone/Fax

Practice location:
  • Phone: 802-651-7533
  • Fax:
Mailing address:
  • Phone: 802-651-7533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number048 0000298
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: