Provider Demographics
NPI:1740489137
Name:RILEY, CARMEN J (MED, LPC)
Entity type:Individual
Prefix:MRS
First Name:CARMEN
Middle Name:J
Last Name:RILEY
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:MS
Other - First Name:CARMEN
Other - Middle Name:J
Other - Last Name:ORTIZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED, LPC
Mailing Address - Street 1:15915 CANADA GOOSE LOOP
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-5562
Mailing Address - Country:US
Mailing Address - Phone:571-989-2927
Mailing Address - Fax:
Practice Address - Street 1:15915 CANADA GOOSE LOOP
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-5562
Practice Address - Country:US
Practice Address - Phone:571-989-2927
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-16
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPRC14584101YM0800X
VA0701006505101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health