Provider Demographics
NPI:1508683053
Name:RILEY, NICOLE (MA, LLPC)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:
Last Name:RILEY
Suffix:
Gender:F
Credentials:MA, LLPC
Other - Prefix:MISS
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:MENDEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10875 DOUGLAS DR
Mailing Address - Street 2:
Mailing Address - City:ALLENDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49401-7406
Mailing Address - Country:US
Mailing Address - Phone:773-951-5243
Mailing Address - Fax:
Practice Address - Street 1:678 FRONT AVE NW STE 100
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49504-5323
Practice Address - Country:US
Practice Address - Phone:616-916-3711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-25
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451023916101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor