Provider Demographics
NPI:1467872655
Name:RILEY, PAMELA GRACE (MA, NCC, LBS, LPC)
Entity Type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:GRACE
Last Name:RILEY
Suffix:
Gender:F
Credentials:MA, NCC, LBS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7145 MIKE WOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:CONNEAUT LAKE
Mailing Address - State:PA
Mailing Address - Zip Code:16316-6527
Mailing Address - Country:US
Mailing Address - Phone:814-332-0359
Mailing Address - Fax:
Practice Address - Street 1:18278 TECHNOLOGY DR
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-8380
Practice Address - Country:US
Practice Address - Phone:814-332-0095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-26
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC007571101YP2500X
PABH000261103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst