Provider Demographics
NPI:1720157183
Name:RILEY, DAVID (LCSW)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:RILEY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2470 SWEET WATER CT
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-3045
Mailing Address - Country:US
Mailing Address - Phone:719-534-9063
Mailing Address - Fax:
Practice Address - Street 1:179 PARKSIDE DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-3130
Practice Address - Country:US
Practice Address - Phone:719-572-6300
Practice Address - Fax:719-572-6399
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9923041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
COH1648Medicare UPIN