Provider Demographics
NPI:1619125044
Name:RILEY, CHANDA ELAINE (PTA)
Entity Type:Individual
Prefix:
First Name:CHANDA
Middle Name:ELAINE
Last Name:RILEY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:592 JOHN ST
Mailing Address - Street 2:
Mailing Address - City:LAKE HELEN
Mailing Address - State:FL
Mailing Address - Zip Code:32744-2009
Mailing Address - Country:US
Mailing Address - Phone:386-624-1582
Mailing Address - Fax:
Practice Address - Street 1:592 JOHN ST
Practice Address - Street 2:
Practice Address - City:LAKE HELEN
Practice Address - State:FL
Practice Address - Zip Code:32744-2009
Practice Address - Country:US
Practice Address - Phone:386-624-1582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-27
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA21014225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant