Provider Demographics
NPI:1952311300
Name:RILEY, LAURIE J (CAC1)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:J
Last Name:RILEY
Suffix:
Gender:F
Credentials:CAC1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21925 FRESARD ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-1254
Mailing Address - Country:US
Mailing Address - Phone:586-775-4066
Mailing Address - Fax:
Practice Address - Street 1:1400 E 12 MILE RD
Practice Address - Street 2:
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-2651
Practice Address - Country:US
Practice Address - Phone:248-547-2223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)