Provider Demographics
NPI:1811084429
Name:RILEY, DEANA (LPC, CPCS)
Entity type:Individual
Prefix:
First Name:DEANA
Middle Name:
Last Name:RILEY
Suffix:
Gender:F
Credentials:LPC, CPCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 GOVERNORS SQ STE B
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-4862
Mailing Address - Country:US
Mailing Address - Phone:770-451-0404
Mailing Address - Fax:
Practice Address - Street 1:130 GOVERNORS SQ STE B
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-4862
Practice Address - Country:US
Practice Address - Phone:770-713-8023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002029101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA55-0872146OtherFEDERAL TAX ID
GA1457876906OtherTHE CENTER FOR LIVING BALANCE