Provider Demographics
NPI:1881291383
Name:RILEY, REGINA MARIE (CTRS, CDP)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:MARIE
Last Name:RILEY
Suffix:
Gender:F
Credentials:CTRS, CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 KING COLLIER RD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-9397
Mailing Address - Country:US
Mailing Address - Phone:769-798-5017
Mailing Address - Fax:
Practice Address - Street 1:1500 E WOODROW WILSON AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-5116
Practice Address - Country:US
Practice Address - Phone:601-362-4471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-07
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS62084225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist