Provider Demographics
NPI:1205387990
Name:RIDDLE, KIRK REMON (LICENSED PROFESSIONA)
Entity Type:Individual
Prefix:MR
First Name:KIRK
Middle Name:REMON
Last Name:RIDDLE
Suffix:
Gender:M
Credentials:LICENSED PROFESSIONA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8627 S. WOOD STREET
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60620
Mailing Address - Country:US
Mailing Address - Phone:904-502-3007
Mailing Address - Fax:
Practice Address - Street 1:1525 E. 53RD STREET, SUITE 425
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615
Practice Address - Country:US
Practice Address - Phone:773-819-5504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-18
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL01YP2500X101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional