Provider Demographics
NPI:1992308621
Name:RILEY, VICTORIA TACKETT
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:TACKETT
Last Name:RILEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:L
Other - Last Name:TACKETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1324 RICHARDSONS LAKE RD
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29803-9220
Mailing Address - Country:US
Mailing Address - Phone:803-257-1480
Mailing Address - Fax:
Practice Address - Street 1:1324 RICHARDSONS LAKE RD
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29803-9220
Practice Address - Country:US
Practice Address - Phone:803-257-1480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-17
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst