Provider Demographics
NPI:1477987394
Name:RIVERSIDE PSYCHOTHERAPY, PLLC
Entity Type:Organization
Organization Name:RIVERSIDE PSYCHOTHERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER/THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:SUSAN
Authorized Official - Last Name:SIKES
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC-MHSP
Authorized Official - Phone:423-802-6943
Mailing Address - Street 1:3914 SAINT ELMO AVE STE C
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37409-1269
Mailing Address - Country:US
Mailing Address - Phone:423-802-6943
Mailing Address - Fax:888-508-2869
Practice Address - Street 1:3914 SAINT ELMO AVE STE C
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37409-1269
Practice Address - Country:US
Practice Address - Phone:423-802-6943
Practice Address - Fax:888-508-6829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-27
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2864101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN12087518OtherCAQH PROVIDER ID
TN1669636742OtherNPI INDIVIDUAL NUMBER