Provider Demographics
NPI:1629092416
Name:RILEY, RUTH ELIZABETH (LPC)
Entity Type:Individual
Prefix:
First Name:RUTH
Middle Name:ELIZABETH
Last Name:RILEY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:RUTH
Other - Middle Name:
Other - Last Name:NICOLAYSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:425 FAIRVIEW AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-1924
Mailing Address - Country:US
Mailing Address - Phone:580-765-3900
Mailing Address - Fax:580-765-7256
Practice Address - Street 1:425 FAIRVIEW AVE STE 3
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-1924
Practice Address - Country:US
Practice Address - Phone:580-765-3900
Practice Address - Fax:580-765-7256
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3506101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional