Provider Demographics
NPI:1528087244
Name:REILLY, KEVIN J (PSYD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:J
Last Name:REILLY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
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 EAST HAMPDEN AVENUE
Practice Address - Street 2:SUITE 420
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80113
Practice Address - Country:US
Practice Address - Phone:303-523-3023
Practice Address - Fax:303-523-3023
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1407103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07014079Medicaid
COC62306Medicare ID - Type Unspecified
CO07014079Medicaid