Provider Demographics
NPI:1538492335
Name:RILEY, MARY KAY (MA, LPC)
Entity Type:Individual
Prefix:MRS
First Name:MARY KAY
Middle Name:
Last Name:RILEY
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:MRS
Other - First Name:MARY KAY
Other - Middle Name:
Other - Last Name:TAUBE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:189 W CLARKSTON RD STE 210
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48362-2892
Mailing Address - Country:US
Mailing Address - Phone:248-568-6401
Mailing Address - Fax:
Practice Address - Street 1:189 W CLARKSTON RD BLDG B
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48362-2892
Practice Address - Country:US
Practice Address - Phone:248-568-6401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-10
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401012077101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1883825Medicaid