Healthcare Provider Details

I. General information

NPI: 1760806996
Provider Name (Legal Business Name): WILLIAM TOBIAS RILEY LPC-S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2014
Last Update Date: 02/17/2022
Certification Date: 02/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

499 KEYWOOD CIR STE A
FLOWOOD MS
39232-3001
US

IV. Provider business mailing address

499 KEYWOOD CIR STE A
FLOWOOD MS
39232-3001
US

V. Phone/Fax

Practice location:
  • Phone: 601-397-0070
  • Fax: 601-397-0252
Mailing address:
  • Phone: 601-397-0070
  • Fax: 601-397-0252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1601
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1601
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: