Provider Demographics
NPI:1902515604
Name:REILLEY, SHANNON (LCPC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:REILLEY
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 N HIGGINS AVE STE 123
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-4563
Mailing Address - Country:US
Mailing Address - Phone:406-550-5150
Mailing Address - Fax:
Practice Address - Street 1:415 N HIGGINS AVE STE 123
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4563
Practice Address - Country:US
Practice Address - Phone:406-550-5150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-21
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LCPC-LIC-69917101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health