Provider Demographics
NPI:1649729971
Name:RIDDLE, COURTNEY
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:RIDDLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4835 S FULTON AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-6976
Mailing Address - Country:US
Mailing Address - Phone:918-591-3071
Mailing Address - Fax:918-615-2261
Practice Address - Street 1:4835 S FULTON AVE STE 100
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-6976
Practice Address - Country:US
Practice Address - Phone:918-591-3071
Practice Address - Fax:918-615-2261
Is Sole Proprietor?:No
Enumeration Date:2016-09-28
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7296101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional