Provider Demographics
NPI:1790281137
Name:RILEY, SAMANTHA AMANDA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:AMANDA
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:PO BOX 6553
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33807-6553
Mailing Address - Country:US
Mailing Address - Phone:863-602-0698
Mailing Address - Fax:813-354-2715
Practice Address - Street 1:1284 DEVIN OAKS CT
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33811-2383
Practice Address - Country:US
Practice Address - Phone:863-602-0698
Practice Address - Fax:813-354-2715
Is Sole Proprietor?:No
Enumeration Date:2018-04-04
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-18-8535106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst