Provider Demographics
NPI:1073169009
Name:REILLY, MCKENZIE LEE (MA, BCBA, LBA)
Entity type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:LEE
Last Name:REILLY
Suffix:
Gender:F
Credentials:MA, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 PROGRESS DR STE 2B
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-6294
Mailing Address - Country:US
Mailing Address - Phone:401-932-1563
Mailing Address - Fax:
Practice Address - Street 1:10 PROGRESS DR STE 2B
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-6294
Practice Address - Country:US
Practice Address - Phone:475-239-5512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-15
Last Update Date:2024-11-05
Deactivation Date:2024-10-21
Deactivation Code:
Reactivation Date:2024-11-05
Provider Licenses
StateLicense IDTaxonomies
CT1-24-76102103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst