1649775917 NPI number — NATHIFA GRACE MKATE RILEY LMSW

Table of content: NATHIFA GRACE MKATE RILEY LMSW (NPI 1649775917)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649775917 NPI number — NATHIFA GRACE MKATE RILEY LMSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RILEY
Provider First Name:
NATHIFA
Provider Middle Name:
GRACE MKATE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649775917
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/30/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 401251
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
REDFORD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48240-9251
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-598-8381
Provider Business Mailing Address Fax Number:
313-543-3237

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
26150 5 MILE RD
Provider Second Line Business Practice Location Address:
STE 33
Provider Business Practice Location Address City Name:
REDFORD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48239-3240
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-598-8381
Provider Business Practice Location Address Fax Number:
313-543-3237
Provider Enumeration Date:
03/28/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  6801091910 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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