Provider Demographics
NPI:1043377120
Name:RILEY, CHRISTINA ELLA EMDE (LCSW)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:ELLA EMDE
Last Name:RILEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 E 1025 S
Mailing Address - Street 2:
Mailing Address - City:VICTOR
Mailing Address - State:ID
Mailing Address - Zip Code:83455-5503
Mailing Address - Country:US
Mailing Address - Phone:307-730-7060
Mailing Address - Fax:208-787-5683
Practice Address - Street 1:158 N ORTH FIRST EAST STREET
Practice Address - Street 2:
Practice Address - City:DRIGGS
Practice Address - State:ID
Practice Address - Zip Code:83422
Practice Address - Country:US
Practice Address - Phone:307-730-7060
Practice Address - Fax:208-787-5683
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-267771041C0700X
WYLCSW-3771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW10465Medicare ID - Type Unspecified