Basic Information
| Provider Information | |||||||||
| NPI: | 1356543003 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RILEY | ||||||||
| FirstName: | KATHY | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MFT-I | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5870 ARLINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925042037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516836596 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5870 ARLINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925042037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516836596 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2007 | ||||||||
| LastUpdateDate: | 03/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 03/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | IMF74967 | CA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | 115056 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 7511A | 05 | CA | MEDICAID | 7565A | 01 | CA | OUTPATIENT MENTAL HEALTH | OTHER |