Provider Demographics
NPI:1427646983
Name:RILEY-MERCADO, CARLEEN M (LMSW)
Entity type:Individual
Prefix:
First Name:CARLEEN
Middle Name:M
Last Name:RILEY-MERCADO
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776974
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6982
Mailing Address - Country:US
Mailing Address - Phone:231-672-2119
Mailing Address - Fax:
Practice Address - Street 1:300 LAFAYETTE AVE SE STE 4000
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4692
Practice Address - Country:US
Practice Address - Phone:616-685-6922
Practice Address - Fax:616-685-5101
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-09
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34008995A101Y00000X
MI68011136131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor