Basic Information
Provider Information
NPI: 1003154774
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: RILEY
FirstName: BEVERLY
MiddleName: KAY
NamePrefix:  
NameSuffix:  
Credential: LCSW
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 3158
Address2:  
City: PORTLAND
State: OR
PostalCode: 972083158
CountryCode: US
TelephoneNumber: 5417327950
FaxNumber:  
Practice Location
Address1: 1698 E MCANDREWS RD STE 300
Address2:  
City: MEDFORD
State: OR
PostalCode: 97504
CountryCode: US
TelephoneNumber: 5417327950
FaxNumber:  
Other Information
ProviderEnumerationDate: 01/30/2013
LastUpdateDate: 05/30/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1041C0700XL6954ORY Behavioral Health & Social Service ProvidersSocial WorkerClinical
1041C0700X2012033735MON Behavioral Health & Social Service ProvidersSocial WorkerClinical

No ID Information.


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