Provider Demographics
NPI:1386269983
Name:RILEY, CAROLINE M (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:CAROLINE
Middle Name:M
Last Name:RILEY
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 MAIN ST N UNIT 182
Mailing Address - Street 2:
Mailing Address - City:KIMBERLY
Mailing Address - State:ID
Mailing Address - Zip Code:83341-7008
Mailing Address - Country:US
Mailing Address - Phone:208-421-9659
Mailing Address - Fax:208-268-3878
Practice Address - Street 1:113 MAIN STREET
Practice Address - Street 2:
Practice Address - City:KIMBERLY
Practice Address - State:ID
Practice Address - Zip Code:83341
Practice Address - Country:US
Practice Address - Phone:208-421-9659
Practice Address - Fax:208-268-3878
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-10
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-4298235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID201830028Medicaid