Provider Demographics
NPI:1679786388
Name:RILEY, ROGER (LMHC, LCPC)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:RILEY
Suffix:
Gender:M
Credentials:LMHC, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 NE 22ND DR
Mailing Address - Street 2:
Mailing Address - City:WILTON MANORS
Mailing Address - State:FL
Mailing Address - Zip Code:33305-2118
Mailing Address - Country:US
Mailing Address - Phone:443-310-8753
Mailing Address - Fax:443-378-3540
Practice Address - Street 1:612 NE 22ND DR
Practice Address - Street 2:
Practice Address - City:WILTON MANORS
Practice Address - State:FL
Practice Address - Zip Code:33305-2118
Practice Address - Country:US
Practice Address - Phone:443-310-8753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2022-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC2042101YM0800X
FLMH15872101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health