Basic Information
| Provider Information | |||||||||
| NPI: | 1578012373 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | O'REILLY | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | LICDC-CS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 899 E BROAD ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432051156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142208655 | ||||||||
| FaxNumber: | 6142208658 | ||||||||
| Practice Location | |||||||||
| Address1: | 899 E BROAD ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432051156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142208655 | ||||||||
| FaxNumber: | 6142208658 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2016 | ||||||||
| LastUpdateDate: | 09/22/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 933651 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 933651 | 01 | OH | OHIO CHEMICAL DEPENDENCY PROFESSIONALS BOARD | OTHER |