Provider Demographics
NPI:1881610723
Name:RILEY, PHILLIP RAY (LPC)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:RAY
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 1:6017 REEF POINT LN STE 115
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76135-7005
Mailing Address - Country:US
Mailing Address - Phone:817-455-2758
Mailing Address - Fax:817-237-7351
Practice Address - Street 1:6017 REEF POINT LN STE 115
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76135-7005
Practice Address - Country:US
Practice Address - Phone:817-455-2758
Practice Address - Fax:817-237-7351
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17938101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional