MEDICARE: RUTH ELIZABETH RILEY LPC

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	101YP2500X	Professional Counselor	3506	OK

General Provider Information

NPI Number	:	1629092416
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUTH ELIZABETH RILEY LPC

Provider Business Mailing Address
First Line	:	425 FAIRVIEW AVE STE 3
Second Line	:
City	:	PONCA CITY
State	:	OK
Zip	:	74601-1924
Country	:	US
Telephone Number	:	580-765-3900
Fax Number	:	580-765-7256

Provider Business Practice Location Address
First Line	:	425 FAIRVIEW AVE STE 3
Second Line	:
City	:	PONCA CITY
State	:	OK
Zip	:	74601-1924
Country	:	US
Telephone Number	:	580-765-3900
Fax Number	:	580-765-7256

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

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	07/08/2007

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