Provider Demographics
NPI:1316008014
Name:RILEY, BONNIE D (LP, LPC)
Entity type:Individual
Prefix:MRS
First Name:BONNIE
Middle Name:D
Last Name:RILEY
Suffix:
Gender:F
Credentials:LP, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17244 DOYLE RD
Mailing Address - Street 2:
Mailing Address - City:BOONVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65233-3500
Mailing Address - Country:US
Mailing Address - Phone:660-882-6400
Mailing Address - Fax:660-882-7137
Practice Address - Street 1:17244 DOYLE RD
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:MO
Practice Address - Zip Code:65233-3500
Practice Address - Country:US
Practice Address - Phone:660-882-2377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000538101YP2500X
320900000X
MO01427103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO6136915OtherUNITED BEHAVIORAL HEALTH
MO493221105Medicaid