Provider Demographics
NPI:1528551371
Name:NICKERSON, RILEY CAUDILL (LMSW)
Entity Type:Individual
Prefix:
First Name:RILEY
Middle Name:CAUDILL
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:RILEY
Other - Middle Name:CAUDILL
Other - Last Name:CORNEILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:118 W OAK ST STE 2B
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854-1667
Mailing Address - Country:US
Mailing Address - Phone:517-803-0846
Mailing Address - Fax:
Practice Address - Street 1:5126 W GRAND RIVER AVE STE B
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48906-9124
Practice Address - Country:US
Practice Address - Phone:517-580-2225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-07
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011087171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical