Provider Demographics
NPI:1669004172
Name:RILEY, SPIRIDOULA J (PT, DPT, ATC, MSAT)
Entity Type:Individual
Prefix:
First Name:SPIRIDOULA
Middle Name:J
Last Name:RILEY
Suffix:
Gender:F
Credentials:PT, DPT, ATC, MSAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 BAYBERRY DR
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:NJ
Mailing Address - Zip Code:08873-4208
Mailing Address - Country:US
Mailing Address - Phone:845-863-5310
Mailing Address - Fax:
Practice Address - Street 1:78 BAYBERRY DR
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:NJ
Practice Address - Zip Code:08873-4208
Practice Address - Country:US
Practice Address - Phone:845-863-5310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-12
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT001283002255A2300X
NJ40QA01171600225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer