=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881126100
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JILL L. REILING LCSW LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2017
-----------------------------------------------------
Last Update Date | 03/28/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 103 MILL PLAIN ROAD
-----------------------------------------------------
City | DANBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-702-3008
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16 FARVIEW ROAD
-----------------------------------------------------
City | BROOKFIELD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-702-3008
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOCIAL WORKER
-----------------------------------------------------
Name | MRS. JILL LISA REILING
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 203-702-3008
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number | 004822
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------