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NPI Code Detail

MEDICARE: JOHN REILLY LICSW

MEDICARE: JOHN REILLY LICSW
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11041C0700XClinical Social Worker788MN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1578661419
Entity Type Code : Individual
Provider Name (Legal Business Name) : JOHN REILLY LICSW
Provider Business Mailing Address
First Line : 4123 E LAKE ST
Second Line :
City : MINNEAPOLIS
State : MN
Zip : 55406-2255
Country : US
Telephone Number : 612-728-2061
Fax Number :
Provider Business Practice Location Address
First Line : 4123 E LAKE ST
Second Line :
City : MINNEAPOLIS
State : MN
Zip : 55406-2255
Country : US
Telephone Number : 612-728-2061
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/21/2006
Last Update Date : 07/21/2022

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