Provider Demographics
NPI:1174084065
Name:RILEY, SOPHIE LORAINE (COTA)
Entity type:Individual
Prefix:
First Name:SOPHIE
Middle Name:LORAINE
Last Name:RILEY
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 CONCORD ST APT 205
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-2809
Mailing Address - Country:US
Mailing Address - Phone:323-775-4996
Mailing Address - Fax:
Practice Address - Street 1:7447 SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-1631
Practice Address - Country:US
Practice Address - Phone:818-787-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-25
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4308224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant