Provider Demographics
NPI:1255617270
Name:RILEY, JOANNA LYNN (LOT)
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:LYNN
Last Name:RILEY
Suffix:
Gender:F
Credentials:LOT
Other - Prefix:
Other - First Name:JOANNA
Other - Middle Name:LYNN
Other - Last Name:MCDONALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LOT
Mailing Address - Street 1:PO BOX 14774
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79768-4774
Mailing Address - Country:US
Mailing Address - Phone:432-638-4544
Mailing Address - Fax:
Practice Address - Street 1:1211 ROYALTY AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-2952
Practice Address - Country:US
Practice Address - Phone:432-638-4544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-24
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109122225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation