MEDICARE: PETER ANTHONY RILEY LGSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	22026	MD

General Provider Information

NPI Number	:	1497107700
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PETER ANTHONY RILEY LGSW

Provider Business Mailing Address
First Line	:	9511 WHITE PILLAR TER
Second Line	:
City	:	GAITHERSBURG
State	:	MD
Zip	:	20882-2813
Country	:	US
Telephone Number	:	301-672-1383
Fax Number	:

Provider Business Practice Location Address
First Line	:	9511 WHITE PILLAR TER
Second Line	:
City	:	GAITHERSBURG
State	:	MD
Zip	:	20882-2813
Country	:	US
Telephone Number	:	301-672-1383
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/11/2016
Last Update Date	:	07/11/2016

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