Provider Demographics
NPI:1457080533
Name:RILEY, CHAZARE
Entity Type:Individual
Prefix:
First Name:CHAZARE
Middle Name:
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 1:72 DRAYTON CT
Mailing Address - Street 2:
Mailing Address - City:MIDWAY
Mailing Address - State:GA
Mailing Address - Zip Code:31320-7142
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:72 DRAYTON CT
Practice Address - Street 2:
Practice Address - City:MIDWAY
Practice Address - State:GA
Practice Address - Zip Code:31320-7142
Practice Address - Country:US
Practice Address - Phone:404-697-3608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-06
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-22-218809106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician