Provider Demographics
NPI:1760716658
Name:RILEY INDIVIDUAL, FAMILY, AND MARRIAGE COUNSELING LLC
Entity Type:Organization
Organization Name:RILEY INDIVIDUAL, FAMILY, AND MARRIAGE COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BIRD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-657-0163
Mailing Address - Street 1:PO BOX 708458
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-8458
Mailing Address - Country:US
Mailing Address - Phone:801-657-0163
Mailing Address - Fax:801-568-7856
Practice Address - Street 1:406 W SOUTH JORDAN PKWY
Practice Address - Street 2:SUITE 220B
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-3965
Practice Address - Country:US
Practice Address - Phone:801-657-0163
Practice Address - Fax:801-568-7856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-24
Last Update Date:2009-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4788890-3501251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health