Provider Demographics
NPI:1295160190
Name:EVERSON, RILEY (LCSW)
Entity type:Individual
Prefix:
First Name:RILEY
Middle Name:
Last Name:EVERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27TH SOMDG
Mailing Address - Street 2:224 W D. L. INGRAM AVENUE, BLDG. 1408
Mailing Address - City:CANNON AFB
Mailing Address - State:NM
Mailing Address - Zip Code:88103
Mailing Address - Country:US
Mailing Address - Phone:850-797-1153
Mailing Address - Fax:
Practice Address - Street 1:224 W D. L. INGRAM AVENUE, BLDG. 1408
Practice Address - Street 2:
Practice Address - City:CANNON AFB
Practice Address - State:NM
Practice Address - Zip Code:88103-9365
Practice Address - Country:US
Practice Address - Phone:850-797-1153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-10
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-10020104100000X
1041C0700X, 171M00000X
NMM-108521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator