Provider Demographics
NPI:1083183636
Name:RIDDELL, AMY JEFFRIES (PLPC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:JEFFRIES
Last Name:RIDDELL
Suffix:
Gender:F
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 W MASON ST STE B
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:MO
Mailing Address - Zip Code:64076-1262
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:213 W MASON ST STE B
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:MO
Practice Address - Zip Code:64076-1262
Practice Address - Country:US
Practice Address - Phone:653-229-7816
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-13
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018040821101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health