Provider Demographics
NPI:1205270063
Name:RILEY, TANEISHA (MASTER LEVEL)
Entity type:Individual
Prefix:
First Name:TANEISHA
Middle Name:
Last Name:RILEY
Suffix:
Gender:F
Credentials:MASTER LEVEL
Other - Prefix:
Other - First Name:TANEISHA
Other - Middle Name:
Other - Last Name:RILEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMHC
Mailing Address - Street 1:8090 ATLANTIC BLVD
Mailing Address - Street 2:#H152
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-8429
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:630 W ADAMS ST
Practice Address - Street 2:STE. 304
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-1645
Practice Address - Country:US
Practice Address - Phone:904-600-2675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-24
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH13733101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health