Basic Information
| Provider Information | |||||||||
| NPI: | 1699135517 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCOOL-RILEY | ||||||||
| FirstName: | TYESHA | ||||||||
| MiddleName: | MAECOLE | ||||||||
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| Credential: | MASTERS DEGREE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14600 NW CORNELL RD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972295442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036453581 | ||||||||
| FaxNumber: | 5036909605 | ||||||||
| Practice Location | |||||||||
| Address1: | 17214 SE DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972361282 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037615272 | ||||||||
| FaxNumber: | 5037626250 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2016 | ||||||||
| LastUpdateDate: | 12/16/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.