Provider Demographics
NPI:1790131977
Name:RILEY, SHAWNA B (LADAC)
Entity Type:Individual
Prefix:
First Name:SHAWNA
Middle Name:B
Last Name:RILEY
Suffix:
Gender:F
Credentials:LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6709 PECOS ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87402-5171
Mailing Address - Country:US
Mailing Address - Phone:505-320-5553
Mailing Address - Fax:
Practice Address - Street 1:1313 MISSION AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401
Practice Address - Country:US
Practice Address - Phone:505-327-7218
Practice Address - Fax:505-327-0828
Is Sole Proprietor?:No
Enumeration Date:2016-05-06
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0154441101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)