Provider Demographics
NPI:1942808589
Name:RILEY, BRIDGET THERESE (SAC-IT, BS)
Entity Type:Individual
Prefix:
First Name:BRIDGET
Middle Name:THERESE
Last Name:RILEY
Suffix:
Gender:F
Credentials:SAC-IT, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 STE 136 SUITE 1
Mailing Address - Street 2:
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913
Mailing Address - Country:US
Mailing Address - Phone:608-477-9858
Mailing Address - Fax:
Practice Address - Street 1:840 HWY 136 STE 1
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-9252
Practice Address - Country:US
Practice Address - Phone:608-477-9858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-15
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18881101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI51430Medicaid