Provider Demographics
NPI:1073359618
Name:MORT, RILEY
Entity type:Individual
Prefix:
First Name:RILEY
Middle Name:
Last Name:MORT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1475 SAINT JOHNS AVE
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-3428
Mailing Address - Country:US
Mailing Address - Phone:787-951-9285
Mailing Address - Fax:
Practice Address - Street 1:211 E 7TH AVE STE 220
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2722
Practice Address - Country:US
Practice Address - Phone:787-951-9285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-03
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR15865104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker