Provider Demographics
NPI:1053776963
Name:REILLY, MARY (LPC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:REILLY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:FOUNTAIN
Other - Middle Name:WORKS
Other - Last Name:COUNSELING
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:495 EDGEWOOD PL
Mailing Address - Street 2:
Mailing Address - City:RUTHERFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07070-2607
Mailing Address - Country:US
Mailing Address - Phone:908-642-2383
Mailing Address - Fax:
Practice Address - Street 1:495 EDGEWOOD PL
Practice Address - Street 2:
Practice Address - City:RUTHERFORD
Practice Address - State:NJ
Practice Address - Zip Code:07070-2607
Practice Address - Country:US
Practice Address - Phone:908-642-2383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-18
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC003984000101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional