Provider Demographics
NPI:1669582128
Name:RILEY, TIFFANY ANNE (MSC LCPC)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:ANNE
Last Name:RILEY
Suffix:
Gender:F
Credentials:MSC LCPC
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:ANNE
Other - Last Name:RUH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSC LCPC
Mailing Address - Street 1:PO BOX 572
Mailing Address - Street 2:
Mailing Address - City:CONRAD
Mailing Address - State:MT
Mailing Address - Zip Code:59425-0572
Mailing Address - Country:US
Mailing Address - Phone:406-366-5644
Mailing Address - Fax:
Practice Address - Street 1:210 S WISCONSIN ST
Practice Address - Street 2:
Practice Address - City:CONRAD
Practice Address - State:MT
Practice Address - Zip Code:59425-2022
Practice Address - Country:US
Practice Address - Phone:406-366-5644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1119101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT200013555Medicaid
MT0256836Medicaid