Provider Demographics
NPI:1962834895
Name:REILLY, GARRETT BEAU (PT)
Entity type:Individual
Prefix:DR
First Name:GARRETT
Middle Name:BEAU
Last Name:REILLY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 S FLORENCE ST
Mailing Address - Street 2:APT B
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-5475
Mailing Address - Country:US
Mailing Address - Phone:928-499-7311
Mailing Address - Fax:
Practice Address - Street 1:3150 N WINDING BROOK RD
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-0972
Practice Address - Country:US
Practice Address - Phone:928-774-7106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-01
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10448225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist