Provider Demographics
NPI:1124558713
Name:RILEY, GLEN
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:
Last Name:RILEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:895 BLUE HILL AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02124-2902
Mailing Address - Country:US
Mailing Address - Phone:860-470-4566
Mailing Address - Fax:
Practice Address - Street 1:895 BLUE HILL AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02124
Practice Address - Country:US
Practice Address - Phone:860-470-4566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health