Provider Demographics
NPI:1013383850
Name:RILEY, IVY KATHERINE
Entity Type:Individual
Prefix:
First Name:IVY
Middle Name:KATHERINE
Last Name:RILEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 528
Mailing Address - Street 2:ATTN: BH DD SERVICES
Mailing Address - City:BETHEL
Mailing Address - State:AK
Mailing Address - Zip Code:99559-0528
Mailing Address - Country:US
Mailing Address - Phone:907-543-2762
Mailing Address - Fax:907-543-3152
Practice Address - Street 1:460 RIDGECREST DRIVE
Practice Address - Street 2:SUITE 215
Practice Address - City:BETHEL
Practice Address - State:AK
Practice Address - Zip Code:99559
Practice Address - Country:US
Practice Address - Phone:907-543-2762
Practice Address - Fax:907-543-3152
Is Sole Proprietor?:No
Enumeration Date:2015-08-17
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1002447Medicaid