Provider Demographics
NPI:1285829689
Name:RIDDLE, BETHANY CLARKE (PHD)
Entity Type:Individual
Prefix:DR
First Name:BETHANY
Middle Name:CLARKE
Last Name:RIDDLE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1099 N COUNTRY RD
Mailing Address - Street 2:RT 25 A
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-1924
Mailing Address - Country:US
Mailing Address - Phone:631-655-2714
Mailing Address - Fax:
Practice Address - Street 1:100 NICHOLLS RD.
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-3100
Practice Address - Country:US
Practice Address - Phone:631-632-6720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-09
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017314103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical