Provider Demographics
NPI:1649064304
Name:RIDDICK, QUI-SHAYNE (CAMS)
Entity type:Individual
Prefix:
First Name:QUI-SHAYNE
Middle Name:
Last Name:RIDDICK
Suffix:
Gender:
Credentials:CAMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 132
Mailing Address - Street 2:
Mailing Address - City:HENRYVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18332-0132
Mailing Address - Country:US
Mailing Address - Phone:718-974-3939
Mailing Address - Fax:
Practice Address - Street 1:5540 MOSHOLU AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10471-2423
Practice Address - Country:US
Practice Address - Phone:718-974-3939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-08
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10328101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor