Provider Demographics
NPI:1083384481
Name:LUDWIG, RILEY
Entity Type:Individual
Prefix:
First Name:RILEY
Middle Name:
Last Name:LUDWIG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16587 ENTERPRISE DR STE E
Mailing Address - Street 2:
Mailing Address - City:THREE RIVERS
Mailing Address - State:MI
Mailing Address - Zip Code:49093-7902
Mailing Address - Country:US
Mailing Address - Phone:269-718-8234
Mailing Address - Fax:
Practice Address - Street 1:16587 ENTERPRISE DR STE E
Practice Address - Street 2:
Practice Address - City:THREE RIVERS
Practice Address - State:MI
Practice Address - Zip Code:49093-7902
Practice Address - Country:US
Practice Address - Phone:269-244-4172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-16
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6852093887APP23104100000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No104100000XBehavioral Health & Social Service ProvidersSocial Worker