MEDICARE: PHILLIP RAY RILEY LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	17938	TX

General Provider Information

NPI Number	:	1881610723
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHILLIP RAY RILEY LPC

Provider Business Mailing Address
First Line	:	6017 REEF POINT LN STE 115
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76135-7005
Country	:	US
Telephone Number	:	817-455-2758
Fax Number	:	817-237-7351

Provider Business Practice Location Address
First Line	:	6017 REEF POINT LN STE 115
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76135-7005
Country	:	US
Telephone Number	:	817-455-2758
Fax Number	:	817-237-7351

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/14/2006
Last Update Date	:	09/13/2019

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