=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598958159
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEVE K RILEY MA, LPC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2007
-----------------------------------------------------
Last Update Date | 08/27/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2390 AMERICAN LEGION BLVD SUITE 2
-----------------------------------------------------
City | MOUNTAIN HOME
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83647-3109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-587-8095
-----------------------------------------------------
Fax | 208-587-8025
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1083
-----------------------------------------------------
City | MOUNTAIN HOME
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83647-1083
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-587-8095
-----------------------------------------------------
Fax | 208-587-8025
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 3779
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------