Provider Demographics
NPI:1659114304
Name:RILEY, CHARMAINE EVETTE (COTA)
Entity type:Individual
Prefix:
First Name:CHARMAINE
Middle Name:EVETTE
Last Name:RILEY
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2015 S LOVINGTON DR APT 105
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-5818
Mailing Address - Country:US
Mailing Address - Phone:313-505-3778
Mailing Address - Fax:
Practice Address - Street 1:2685 W MAPLE RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-7122
Practice Address - Country:US
Practice Address - Phone:248-965-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-18
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202006835224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant