Provider Demographics
NPI:1053982348
Name:RILEY, CHANDLER LLOYD
Entity type:Individual
Prefix:
First Name:CHANDLER
Middle Name:LLOYD
Last Name:RILEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1518 SAMS HILL RD APT 53
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92021-3096
Mailing Address - Country:US
Mailing Address - Phone:323-632-5852
Mailing Address - Fax:
Practice Address - Street 1:1529 GRAND AVE STE A
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92078-2464
Practice Address - Country:US
Practice Address - Phone:760-798-0299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-07
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA121045106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist