Provider Demographics
NPI:1083920482
Name:RILEY, IVONNE (LMSW)
Entity Type:Individual
Prefix:
First Name:IVONNE
Middle Name:
Last Name:RILEY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 MELODY LN S
Mailing Address - Street 2:
Mailing Address - City:SOCORRO
Mailing Address - State:NM
Mailing Address - Zip Code:87801-5029
Mailing Address - Country:US
Mailing Address - Phone:505-363-9606
Mailing Address - Fax:000-000-0000
Practice Address - Street 1:1200 HIGHWAY 60
Practice Address - Street 2:
Practice Address - City:SOCORRO
Practice Address - State:NM
Practice Address - Zip Code:87801
Practice Address - Country:US
Practice Address - Phone:575-835-2444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-23
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-09956104100000X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM22623213Medicaid