Provider Demographics
NPI:1093809204
Name:RILEY-TRYON, KATHLEEN ANNE (LCSW)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ANNE
Last Name:RILEY-TRYON
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 1:622 DEWITT ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-1345
Mailing Address - Country:US
Mailing Address - Phone:315-436-5428
Mailing Address - Fax:315-422-2022
Practice Address - Street 1:530 OAK ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-1652
Practice Address - Country:US
Practice Address - Phone:315-436-5428
Practice Address - Fax:315-422-2022
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY069916-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP89529Medicare UPIN