MEDICARE: LAURIE J RILEY CAC1

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	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1952311300
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURIE J RILEY CAC1

Provider Business Mailing Address
First Line	:	21925 FRESARD ST
Second Line	:
City	:	SAINT CLAIR SHORES
State	:	MI
Zip	:	48080-1254
Country	:	US
Telephone Number	:	586-775-4066
Fax Number	:

Provider Business Practice Location Address
First Line	:	1400 E 12 MILE RD
Second Line	:
City	:	MADISON HEIGHTS
State	:	MI
Zip	:	48071-2651
Country	:	US
Telephone Number	:	248-547-2223
Fax Number	:

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

Provider Enumeration Date	:	08/08/2006
Last Update Date	:	07/08/2007

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