Provider Demographics
NPI:1144551656
Name:REILLY, JOHANNAH (ND, LAC)
Entity type:Individual
Prefix:DR
First Name:JOHANNAH
Middle Name:
Last Name:REILLY
Suffix:
Gender:F
Credentials:ND, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2760 29TH ST
Mailing Address - Street 2:SUITE 2E
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-1214
Mailing Address - Country:US
Mailing Address - Phone:303-541-9600
Mailing Address - Fax:303-938-9402
Practice Address - Street 1:2760 29TH ST
Practice Address - Street 2:SUITE 2E
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1214
Practice Address - Country:US
Practice Address - Phone:303-541-9600
Practice Address - Fax:303-938-9402
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-22
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO120171100000X
MT30175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No175F00000XOther Service ProvidersNaturopath