Provider Demographics
NPI:1225287089
Name:RILEY, LISA (COTA/L)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:RILEY
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 SHORT ST
Mailing Address - Street 2:
Mailing Address - City:BLUFORD
Mailing Address - State:IL
Mailing Address - Zip Code:62814-1229
Mailing Address - Country:US
Mailing Address - Phone:618-315-1964
Mailing Address - Fax:
Practice Address - Street 1:208 ZACHERY DR
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6712
Practice Address - Country:US
Practice Address - Phone:618-204-5497
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-16
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.002213224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant