Provider Demographics
NPI:1720435548
Name:RILEY, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:RILEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 DELANCO RD
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:08010-1603
Mailing Address - Country:US
Mailing Address - Phone:609-321-4776
Mailing Address - Fax:
Practice Address - Street 1:711 DELANCO RD
Practice Address - Street 2:
Practice Address - City:EDGEWATER PARK
Practice Address - State:NJ
Practice Address - Zip Code:08010-1603
Practice Address - Country:US
Practice Address - Phone:609-321-4776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-23
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health