Provider Demographics
NPI:1063074912
Name:REILLY, CHRISTOPHER
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:REILLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 MOORPARK AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-2680
Mailing Address - Country:US
Mailing Address - Phone:408-975-2730
Mailing Address - Fax:
Practice Address - Street 1:2400 MOORPARK AVE STE 300
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-2680
Practice Address - Country:US
Practice Address - Phone:408-975-2730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-01
Last Update Date:2022-05-27
Deactivation Date:2022-03-14
Deactivation Code:
Reactivation Date:2022-03-29
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CAC059990419101YA0400X
CA171M00000X
CAB00001760521101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator