Basic Information
| Provider Information | |||||||||
| NPI: | 1881604106 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REILLY | ||||||||
| FirstName: | CHRISTINE | ||||||||
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| Credential: | M.A., CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1477 HYDE PARK DR | ||||||||
| Address2: | |||||||||
| City: | WINTER PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327928145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4077608988 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3590 N US HIGHWAY 17/92 | ||||||||
| Address2: | SUITE 1038 | ||||||||
| City: | LAKE MARY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327464510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073226222 | ||||||||
| FaxNumber: | 4073225596 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 01/24/2011 | ||||||||
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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 | 235Z00000X | SA 8666 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 8989997 00 | 05 | FL | MEDICAID | SA 8666 | 01 | FL | SPEECH LANGUAGE PATHOLOGY | OTHER |