Provider Demographics
NPI:1750665865
Name:RILEY, TONYA
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:
Last Name:RILEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4212 CORAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-3016
Mailing Address - Country:US
Mailing Address - Phone:912-342-8875
Mailing Address - Fax:912-265-0041
Practice Address - Street 1:130 N GROSS RD
Practice Address - Street 2:
Practice Address - City:KINGSLAND
Practice Address - State:GA
Practice Address - Zip Code:31548-6262
Practice Address - Country:US
Practice Address - Phone:912-342-8875
Practice Address - Fax:912-265-0041
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-07
Last Update Date:2019-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP006377235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist