Provider Demographics
NPI:1124330188
Name:RILEY, SHANDA RETRELL (LCSW)
Entity type:Individual
Prefix:
First Name:SHANDA
Middle Name:RETRELL
Last Name:RILEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:813 INTERSTATE 30
Mailing Address - Street 2:APT. 731
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-7494
Mailing Address - Country:US
Mailing Address - Phone:214-417-6831
Mailing Address - Fax:
Practice Address - Street 1:813 INTERSTATE 30
Practice Address - Street 2:APT. 731
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-7494
Practice Address - Country:US
Practice Address - Phone:214-417-6831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-07
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29588101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health