Provider Demographics
NPI:1235539529
Name:RILEY, CLARENCE JR
Entity Type:Individual
Prefix:MR
First Name:CLARENCE
Middle Name:
Last Name:RILEY
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:892 W CHARING CROSS CIR
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-6426
Mailing Address - Country:US
Mailing Address - Phone:340-513-9178
Mailing Address - Fax:
Practice Address - Street 1:892 W CHARING CROSS CIR
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-6426
Practice Address - Country:US
Practice Address - Phone:340-513-9178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-25
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12600101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL12260OtherFLORIDA DEPARTMENT OF HEALTH