Provider Demographics
NPI:1316238611
Name:KEVIN J. REILLY, PSY.D.,P.C.
Entity type:Organization
Organization Name:KEVIN J. REILLY, PSY.D.,P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:REILLY
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:303-523-3023
Mailing Address - Street 1:601 EAST HAMPDEN AVENUE
Mailing Address - Street 2:SUITE 420
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80113
Mailing Address - Country:US
Mailing Address - Phone:303-523-3023
Mailing Address - Fax:720-212-0344
Practice Address - Street 1:601 E HAMPDEN AVE STE 420
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80113-2770
Practice Address - Country:US
Practice Address - Phone:303-523-3023
Practice Address - Fax:303-523-3023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-21
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1407103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07014079Medicaid
CO07014079Medicaid
COC62306Medicare PIN