Healthcare Provider Details

I. General information

NPI: 1255222428
Provider Name (Legal Business Name): MRS. DEIDRA NICOLE RILEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2025
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4408 FOREST DR STE 102
COLUMBIA SC
29206-3162
US

IV. Provider business mailing address

4408 FOREST DR STE 102
COLUMBIA SC
29206-3162
US

V. Phone/Fax

Practice location:
  • Phone: 949-282-9667
  • Fax:
Mailing address:
  • Phone: 839-246-7989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number12284
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number12284
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number12284
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: