Provider Demographics
NPI:1548428014
Name:RILEY HATHORNE, LINDA (LLPC)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:RILEY HATHORNE
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 SEVILLE ROW
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-2601
Mailing Address - Country:US
Mailing Address - Phone:313-971-4343
Mailing Address - Fax:248-569-7626
Practice Address - Street 1:17352 W 12 MILE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-2119
Practice Address - Country:US
Practice Address - Phone:248-559-0730
Practice Address - Fax:248-569-7626
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-30
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401005921101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6401005921OtherSTATE OF MICHIGAN LICENCE