Provider Demographics
NPI:1376220970
Name:RILEY, SHANNON ARLENE
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:ARLENE
Last Name:RILEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 GRAND CENTRAL BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-4146
Mailing Address - Country:US
Mailing Address - Phone:912-244-3305
Mailing Address - Fax:
Practice Address - Street 1:105 GRAND CENTRAL BLVD STE 101
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-4146
Practice Address - Country:US
Practice Address - Phone:912-244-3305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-05
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician