Provider Demographics
NPI:1790891612
Name:RIDDLE, RICHARD (MSW)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:
Last Name:RIDDLE
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 W.3RD. ST.
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:HI
Mailing Address - Zip Code:45384
Mailing Address - Country:US
Mailing Address - Phone:937-268-6511
Mailing Address - Fax:
Practice Address - Street 1:4100 W.3RD. ST.
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:HI
Practice Address - Zip Code:45384
Practice Address - Country:US
Practice Address - Phone:937-268-6511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI-00032181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHRIDDL7Medicare ID - Type Unspecified