Provider Demographics
NPI:1750433371
Name:RIDDELL, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:RIDDELL
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 1:1305 WEBSTER ROAD
Mailing Address - Street 2:SENECA HEALTH SERVICES INC
Mailing Address - City:SUMMERVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26651
Mailing Address - Country:US
Mailing Address - Phone:304-872-6577
Mailing Address - Fax:304-872-5415
Practice Address - Street 1:1 STEVENS ROAD
Practice Address - Street 2:SENECA HEALTH SERVICES INC
Practice Address - City:SUMMERVILLE
Practice Address - State:WV
Practice Address - Zip Code:26651
Practice Address - Country:US
Practice Address - Phone:304-872-2659
Practice Address - Fax:304-872-1685
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVDP009426021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical