Provider Demographics
NPI:1164032645
Name:RIDDICK, LAUREN TAYLOR
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:TAYLOR
Last Name:RIDDICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1957 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-2705
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1957 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-2705
Practice Address - Country:US
Practice Address - Phone:901-239-2555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-09
Last Update Date:2020-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health