Healthcare Provider Details

I. General information

NPI: 1952311300
Provider Name (Legal Business Name): LAURIE J RILEY CAC1
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 E 12 MILE RD
MADISON HEIGHTS MI
48071-2651
US

IV. Provider business mailing address

21925 FRESARD ST
SAINT CLAIR SHORES MI
48080-1254
US

V. Phone/Fax

Practice location:
  • Phone: 248-547-2223
  • Fax:
Mailing address:
  • Phone: 586-775-4066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: