Provider Demographics
NPI:1558846204
Name:RILEY, LEA (MMT)
Entity Type:Individual
Prefix:
First Name:LEA
Middle Name:
Last Name:RILEY
Suffix:
Gender:F
Credentials:MMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1645 CHURCHILL DR
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-6496
Mailing Address - Country:US
Mailing Address - Phone:501-259-5727
Mailing Address - Fax:
Practice Address - Street 1:607 HARKRIDER ST STE 5
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-5692
Practice Address - Country:US
Practice Address - Phone:501-259-5727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-28
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR8292225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty