Provider Demographics
NPI:1114193331
Name:RIDDLE, LAURA (MA, LMFT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:RIDDLE
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 SAINT DUNSTAN WAY
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-4306
Mailing Address - Country:US
Mailing Address - Phone:407-592-2290
Mailing Address - Fax:
Practice Address - Street 1:315 N LAKEMONT AVE
Practice Address - Street 2:SUITE B
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-3205
Practice Address - Country:US
Practice Address - Phone:407-830-6412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-07
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT 813106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist