Provider Demographics
NPI:1013686310
Name:RILEY, ELLEN MARIE
Entity Type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:MARIE
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 1:8018 ALBRECHT CIR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-5524
Mailing Address - Country:US
Mailing Address - Phone:502-210-9033
Mailing Address - Fax:
Practice Address - Street 1:4420 DIXIE HWY STE 122
Practice Address - Street 2:
Practice Address - City:SHIVELY
Practice Address - State:KY
Practice Address - Zip Code:40216-2986
Practice Address - Country:US
Practice Address - Phone:502-447-2750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-09
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY173069225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist