Healthcare Provider Details

I. General information

NPI: 1851834535
Provider Name (Legal Business Name): MICHAEL RILEY LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2016
Last Update Date: 12/21/2021
Certification Date: 12/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 S ENGLE ST LOT 88
AURORA MO
65605-2749
US

IV. Provider business mailing address

1600 S ENGLE ST LOT 88
AURORA MO
65605-2749
US

V. Phone/Fax

Practice location:
  • Phone: 417-597-9604
  • Fax:
Mailing address:
  • Phone: 417-597-9604
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number2016041527
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: