Provider Demographics
NPI:1902404122
Name:RILEY, DORREAN (TLLP)
Entity Type:Individual
Prefix:MR
First Name:DORREAN
Middle Name:
Last Name:RILEY
Suffix:
Gender:M
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19189 LEXINGTON
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48240-2618
Mailing Address - Country:US
Mailing Address - Phone:313-204-9118
Mailing Address - Fax:
Practice Address - Street 1:19189 LEXINGTON
Practice Address - Street 2:
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48240-2618
Practice Address - Country:US
Practice Address - Phone:313-204-9118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362009003103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty