Provider Demographics
NPI:1851834535
Name:RILEY, MICHAEL (LPC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:RILEY
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 S ENGLE ST LOT 88
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:MO
Mailing Address - Zip Code:65605-2749
Mailing Address - Country:US
Mailing Address - Phone:417-597-9604
Mailing Address - Fax:
Practice Address - Street 1:1600 S ENGLE ST LOT 88
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:MO
Practice Address - Zip Code:65605-2749
Practice Address - Country:US
Practice Address - Phone:417-597-9604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-29
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 101YM0800X
MO2016041527101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor