Basic Information
| Provider Information | |||||||||
| NPI: | 1710455472 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REILLY | ||||||||
| FirstName: | COLLEEN | ||||||||
| MiddleName: | LOUISE | ||||||||
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| Credential: | MSW, LCSW, LCASA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1502 W NC HIGHWAY 54 | ||||||||
| Address2: | STE 103 | ||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277075572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193540840 | ||||||||
| FaxNumber: | 9197484441 | ||||||||
| Practice Location | |||||||||
| Address1: | 3505 N ROXBORO ST | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277042767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192204224 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2018 | ||||||||
| LastUpdateDate: | 11/19/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LCAS-22966 | NC | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | C011863 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.