Provider Demographics
NPI:1912646209
Name:RIDDICK, MARCELLER RAINA
Entity Type:Individual
Prefix:
First Name:MARCELLER
Middle Name:RAINA
Last Name:RIDDICK
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 1:7000 WOODMARK DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-8422
Mailing Address - Country:US
Mailing Address - Phone:252-339-6834
Mailing Address - Fax:
Practice Address - Street 1:402 HARRIS AVE
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-3112
Practice Address - Country:US
Practice Address - Phone:910-875-5590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-03
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-28013101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)