Provider Demographics
NPI:1417188822
Name:RIDDELL, KILLORIN MAUREEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:KILLORIN
Middle Name:MAUREEN
Last Name:RIDDELL
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 1:11305 ELIANO STREET
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93422
Mailing Address - Country:US
Mailing Address - Phone:310-621-7965
Mailing Address - Fax:
Practice Address - Street 1:11305 ELIANO STREET
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422
Practice Address - Country:US
Practice Address - Phone:310-621-7965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-03
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 13275103T00000X, 103TC0700X
CAPSY13275103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical