Provider Demographics
NPI:1578070272
Name:RILEY, CHARISA MARIE DANIELLE
Entity Type:Individual
Prefix:
First Name:CHARISA
Middle Name:MARIE DANIELLE
Last Name:RILEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHARISA
Other - Middle Name:MARIE DANIELLE
Other - Last Name:ZACHARIOU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4540 HARLIN DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95826-9716
Mailing Address - Country:US
Mailing Address - Phone:909-484-2848
Mailing Address - Fax:
Practice Address - Street 1:4540 HARLIN DR
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95826-9716
Practice Address - Country:US
Practice Address - Phone:909-484-2848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-03
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17-44339106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician