Provider Demographics
NPI:1972680668
Name:REILLY, RICHARD DEAN (LCPC)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:DEAN
Last Name:REILLY
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10400 RIDGLAND RD
Mailing Address - Street 2:STE 1
Mailing Address - City:COCKEYSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21030-2715
Mailing Address - Country:US
Mailing Address - Phone:410-628-6120
Mailing Address - Fax:410-628-9825
Practice Address - Street 1:10400 RIDGLAND RD
Practice Address - Street 2:STE 1
Practice Address - City:COCKEYSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21030-2715
Practice Address - Country:US
Practice Address - Phone:410-628-6120
Practice Address - Fax:410-628-0953
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC2216101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD410893100Medicaid