Provider Demographics
NPI:1902939556
Name:RILEY, ELIZABETH G (PT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:G
Last Name:RILEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:KRAATZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1106 WALNUT ST
Mailing Address - Street 2:STE 110
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-2416
Mailing Address - Country:US
Mailing Address - Phone:805-788-0805
Mailing Address - Fax:805-788-0845
Practice Address - Street 1:2901 PARK AVE
Practice Address - Street 2:STE B1
Practice Address - City:SOQUEL
Practice Address - State:CA
Practice Address - Zip Code:95073-2831
Practice Address - Country:US
Practice Address - Phone:831-706-2085
Practice Address - Fax:831-417-3799
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT11568225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT11568OtherMED LICENSE #