Provider Demographics
NPI:1720420516
Name:RILEY, KIMBERLY A (LICSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:RILEY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 COLCHESTER ST
Mailing Address - Street 2:
Mailing Address - City:HYDE PARK
Mailing Address - State:MA
Mailing Address - Zip Code:02136-2450
Mailing Address - Country:US
Mailing Address - Phone:508-254-9587
Mailing Address - Fax:
Practice Address - Street 1:33 UNION ST
Practice Address - Street 2:
Practice Address - City:SOUTH WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190-2336
Practice Address - Country:US
Practice Address - Phone:508-254-9587
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-23
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1142311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical