Provider Demographics
NPI:1003979642
Name:RILEY, CAROL (LCSW LMP)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:
Last Name:RILEY
Suffix:
Gender:F
Credentials:LCSW LMP
Other - Prefix:MS
Other - First Name:CAROL
Other - Middle Name:
Other - Last Name:RILEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW LMP
Mailing Address - Street 1:4649 SUNNYSIDE AVE NO
Mailing Address - Street 2:SUITE 340
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-6955
Mailing Address - Country:US
Mailing Address - Phone:206-545-4266
Mailing Address - Fax:
Practice Address - Street 1:4649 SUNNYSIDE AVE NO
Practice Address - Street 2:SUITE 340
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-6955
Practice Address - Country:US
Practice Address - Phone:206-545-4266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000052461041C0700X
WAMA00000248225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8859877Medicare ID - Type Unspecified