Provider Demographics
NPI:1710166111
Name:RILEY, JAMES EDWIN (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:EDWIN
Last Name:RILEY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 WAGON TRAIL LN
Mailing Address - Street 2:
Mailing Address - City:GOLDSBY
Mailing Address - State:OK
Mailing Address - Zip Code:73093-9153
Mailing Address - Country:US
Mailing Address - Phone:405-288-2611
Mailing Address - Fax:
Practice Address - Street 1:1025 WAGON TRAIL LN
Practice Address - Street 2:
Practice Address - City:GOLDSBY
Practice Address - State:OK
Practice Address - Zip Code:73093-9153
Practice Address - Country:US
Practice Address - Phone:405-288-2611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-01
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK34841041C0700X
OK39531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical