Provider Demographics
NPI:1780958132
Name:RIDDELL, JOHN CHARLES (CADC I)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:CHARLES
Last Name:RIDDELL
Suffix:
Gender:M
Credentials:CADC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1575 19TH ST NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-7931
Mailing Address - Country:US
Mailing Address - Phone:503-585-6255
Mailing Address - Fax:
Practice Address - Street 1:2035 DAVCOR ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-1595
Practice Address - Country:US
Practice Address - Phone:503-576-4660
Practice Address - Fax:503-361-2688
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-02
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)