Provider Demographics
NPI:1811649833
Name:DR. DONNA RILEY OFFICE OF LICENSED CLINICAL SOCIAL WORK, PLLC
Entity type:Organization
Organization Name:DR. DONNA RILEY OFFICE OF LICENSED CLINICAL SOCIAL WORK, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:BARBARA
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LCSW-R
Authorized Official - Phone:516-983-1780
Mailing Address - Street 1:2233 NESCONSET HWY STE 100
Mailing Address - Street 2:
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755-1000
Mailing Address - Country:US
Mailing Address - Phone:631-602-7856
Mailing Address - Fax:631-602-7857
Practice Address - Street 1:2233 NESCONSET HWY STE 100
Practice Address - Street 2:
Practice Address - City:LAKE GROVE
Practice Address - State:NY
Practice Address - Zip Code:11755-1000
Practice Address - Country:US
Practice Address - Phone:631-602-7856
Practice Address - Fax:631-602-7857
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-20
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03364918Medicaid