Provider Demographics
NPI:1104081454
Name:RIDDLE, BRAD A (DMIN, LMHP)
Entity type:Individual
Prefix:DR
First Name:BRAD
Middle Name:A
Last Name:RIDDLE
Suffix:
Gender:M
Credentials:DMIN, LMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5505 RED ROCK LN
Mailing Address - Street 2:SUITE 400
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-2520
Mailing Address - Country:US
Mailing Address - Phone:402-613-0992
Mailing Address - Fax:
Practice Address - Street 1:5505 RED ROCK LN
Practice Address - Street 2:SUITE 400
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-2520
Practice Address - Country:US
Practice Address - Phone:402-613-0992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-25
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1875101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health