Provider Demographics
NPI:1316374028
Name:RILEY, BRYAN WAYNE
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:WAYNE
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 1:210 TACOMA ST
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-9370
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:210 TACOMA ST
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-9370
Practice Address - Country:US
Practice Address - Phone:541-476-3302
Practice Address - Fax:541-476-2895
Is Sole Proprietor?:No
Enumeration Date:2013-09-27
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health