Provider Demographics
NPI:1295276640
Name:RILEY, TINA (LICSW)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:RILEY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:
Other - Last Name:MEYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1025 MARSH ST
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-4752
Mailing Address - Country:US
Mailing Address - Phone:507-385-5761
Mailing Address - Fax:507-594-5797
Practice Address - Street 1:1025 MARSH ST
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-4752
Practice Address - Country:US
Practice Address - Phone:507-385-5761
Practice Address - Fax:507-594-5797
Is Sole Proprietor?:No
Enumeration Date:2017-03-18
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN183321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical