Provider Demographics
NPI:1730398751
Name:REILLY, STEPHANIE (PT, DPT, PCS, C/NDT)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:
Last Name:REILLY
Suffix:
Gender:F
Credentials:PT, DPT, PCS, C/NDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 SPRUCE KNLS
Mailing Address - Street 2:
Mailing Address - City:PUTNAM VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:10579-2038
Mailing Address - Country:US
Mailing Address - Phone:152-868-9856
Mailing Address - Fax:
Practice Address - Street 1:1400 OLD COUNTRY RD STE C103N
Practice Address - Street 2:
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590-5156
Practice Address - Country:US
Practice Address - Phone:215-868-9856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2025-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT017474225100000X
NY031900-12251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101472902Medicaid