Provider Demographics
NPI:1700563962
Name:RIDDICK, BOBBY RAY JR
Entity Type:Individual
Prefix:MR
First Name:BOBBY
Middle Name:RAY
Last Name:RIDDICK
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 THOR ST APT A
Mailing Address - Street 2:
Mailing Address - City:SHEPPARD AFB
Mailing Address - State:TX
Mailing Address - Zip Code:76311-4417
Mailing Address - Country:US
Mailing Address - Phone:804-939-0653
Mailing Address - Fax:
Practice Address - Street 1:5816 ASHLEYANNE CIR STE 400
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76310-1613
Practice Address - Country:US
Practice Address - Phone:940-757-0660
Practice Address - Fax:940-757-0663
Is Sole Proprietor?:No
Enumeration Date:2023-06-29
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-23-281923106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician