Healthcare Provider Details

I. General information

NPI: 1710817606
Provider Name (Legal Business Name): JOHNAE LA'ESSIECA RILEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2026
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

529 COUNTY ROAD 67
SELMA AL
36701-1415
US

IV. Provider business mailing address

529 COUNTY ROAD 67
SELMA AL
36701-1415
US

V. Phone/Fax

Practice location:
  • Phone: 334-505-4353
  • Fax:
Mailing address:
  • Phone: 334-505-4353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberALC04894
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: