Provider Demographics
NPI:1720569056
Name:RIDDLE, BETTY
Entity Type:Individual
Prefix:
First Name:BETTY
Middle Name:
Last Name:RIDDLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BETTY
Other - Middle Name:BURWITZ
Other - Last Name:RIDDLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2623 NE WASCO ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1740
Mailing Address - Country:US
Mailing Address - Phone:503-860-3238
Mailing Address - Fax:
Practice Address - Street 1:4805 NE GLISAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2933
Practice Address - Country:US
Practice Address - Phone:503-215-6059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR185710225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR185710OtherOREGON OT LICENSE