Provider Demographics
NPI:1669985107
Name:RILEY, KRISTEN MARIE (CCC/SLP)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:MARIE
Last Name:RILEY
Suffix:
Gender:F
Credentials:CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 LEANING OAK RD
Mailing Address - Street 2:
Mailing Address - City:BOONES MILL
Mailing Address - State:VA
Mailing Address - Zip Code:24065-3591
Mailing Address - Country:US
Mailing Address - Phone:540-243-1038
Mailing Address - Fax:
Practice Address - Street 1:25 BERNARD RD
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:VA
Practice Address - Zip Code:24151-6614
Practice Address - Country:US
Practice Address - Phone:540-483-5138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-07
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2203000593235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist