Provider Demographics
NPI:1558919647
Name:RILEY, JUDY CARROLL (LMFT)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:CARROLL
Last Name:RILEY
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:JUDY
Other - Middle Name:C
Other - Last Name:RILEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMFT
Mailing Address - Street 1:473 E CARNEGIE DRIVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408
Mailing Address - Country:US
Mailing Address - Phone:909-312-8033
Mailing Address - Fax:909-253-1936
Practice Address - Street 1:625 KANSAS ST APT 11
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-8002
Practice Address - Country:US
Practice Address - Phone:626-831-4673
Practice Address - Fax:909-253-1936
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-31
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA85811106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA84-3391326OtherCOUNSELING