Provider Demographics
NPI:1902112725
Name:RILES, BRIONDA S (COTA/L)
Entity Type:Individual
Prefix:
First Name:BRIONDA
Middle Name:S
Last Name:RILES
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5918 COREY LANE
Mailing Address - Street 2:APT 1BL
Mailing Address - City:OAK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60452
Mailing Address - Country:US
Mailing Address - Phone:708-374-0659
Mailing Address - Fax:
Practice Address - Street 1:5918 COREY LN
Practice Address - Street 2:APT 1BL
Practice Address - City:OAK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60452-2970
Practice Address - Country:US
Practice Address - Phone:708-374-0659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-31
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.003078225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist