Provider Demographics
NPI:1023154911
Name:REILLEY, GENEVIEVE (PHD)
Entity type:Individual
Prefix:DR
First Name:GENEVIEVE
Middle Name:
Last Name:REILLEY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 183
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-0183
Mailing Address - Country:US
Mailing Address - Phone:916-962-2978
Mailing Address - Fax:916-962-2978
Practice Address - Street 1:4112 PENNSYLVANIA AVE STE A8 1
Practice Address - Street 2:
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628
Practice Address - Country:US
Practice Address - Phone:916-962-2978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY6492103G00000X, 103TC0700X, 103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PL64920Medicare ID - Type Unspecified