Provider Demographics
NPI:1164748240
Name:RICCIARDI, LAURIE (PT DPT RDN)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:RICCIARDI
Suffix:
Gender:F
Credentials:PT DPT RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 SPRING FOREST RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-2815
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2404 PLANTATION CENTER DR
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-5299
Practice Address - Country:US
Practice Address - Phone:704-847-9477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-14
Last Update Date:2019-03-21
Deactivation Date:2013-06-27
Deactivation Code:
Reactivation Date:2017-09-21
Provider Licenses
StateLicense IDTaxonomies
133V00000X
NCP13683225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered