MEDICARE: RILEY CORMACK MA, LPCC

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	101YP2500X	Professional Counselor	18	CA

General Provider Information

NPI Number	:	1992976880
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RILEY CORMACK MA, LPCC

Provider Business Mailing Address
First Line	:	2214 5TH AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92101-2104
Country	:	US
Telephone Number	:	619-512-3545
Fax Number	:

Provider Business Practice Location Address
First Line	:	2214 5TH AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92101-2104
Country	:	US
Telephone Number	:	619-512-3545
Fax Number	:

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

Provider Enumeration Date	:	03/18/2008
Last Update Date	:	10/23/2014

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