Basic Information
| Provider Information | |||||||||
| NPI: | 1902380736 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RILEY-CHANNER | ||||||||
| FirstName: | MILDRED | ||||||||
| MiddleName: | AUDREY | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2570 ROUTE 9W STE 10 | ||||||||
| Address2: | |||||||||
| City: | CORNWALL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125181370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452203100 | ||||||||
| FaxNumber: | 8455342940 | ||||||||
| Practice Location | |||||||||
| Address1: | 147 LAKE ST | ||||||||
| Address2: | |||||||||
| City: | NEWBURGH | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125505263 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8455638000 | ||||||||
| FaxNumber: | 8455342940 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2018 | ||||||||
| LastUpdateDate: | 02/20/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 102035-1 | NY | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.