Provider Demographics
NPI:1902380736
Name:RILEY-CHANNER, MILDRED AUDREY (LMSW)
Entity Type:Individual
Prefix:
First Name:MILDRED
Middle Name:AUDREY
Last Name:RILEY-CHANNER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2570 ROUTE 9W STE 10
Mailing Address - Street 2:
Mailing Address - City:CORNWALL
Mailing Address - State:NY
Mailing Address - Zip Code:12518-1370
Mailing Address - Country:US
Mailing Address - Phone:845-220-3100
Mailing Address - Fax:845-534-2940
Practice Address - Street 1:147 LAKE ST
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550-5263
Practice Address - Country:US
Practice Address - Phone:845-563-8000
Practice Address - Fax:845-534-2940
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-18
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY102035-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker