Provider Demographics
NPI:1861939100
Name:REARDON, MICHAEL (LMHC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:REARDON
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:987 RC HOAG DRIVE, LIONEL R JOHN HEALTH CENTER
Mailing Address - Street 2:
Mailing Address - City:SALAMANCA
Mailing Address - State:NY
Mailing Address - Zip Code:14779-1365
Mailing Address - Country:US
Mailing Address - Phone:716-945-9001
Mailing Address - Fax:716-945-0790
Practice Address - Street 1:987 RC HOAG DRIVE, LIONEL R JOHN HEALTH CENTER
Practice Address - Street 2:
Practice Address - City:SALAMANCA
Practice Address - State:NY
Practice Address - Zip Code:14779-1365
Practice Address - Country:US
Practice Address - Phone:716-945-9001
Practice Address - Fax:716-945-0790
Is Sole Proprietor?:No
Enumeration Date:2017-01-25
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000706101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health