Provider Demographics
NPI:1457700122
Name:RIDDICK, ROBERTA
Entity type:Individual
Prefix:
First Name:ROBERTA
Middle Name:
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 1:9 SANDSTONE LN
Mailing Address - Street 2:
Mailing Address - City:STUARTS DRAFT
Mailing Address - State:VA
Mailing Address - Zip Code:24477-2536
Mailing Address - Country:US
Mailing Address - Phone:302-399-8371
Mailing Address - Fax:540-416-4361
Practice Address - Street 1:9 SANDSTONE LN
Practice Address - Street 2:
Practice Address - City:STUARTS DRAFT
Practice Address - State:VA
Practice Address - Zip Code:24477-2536
Practice Address - Country:US
Practice Address - Phone:302-399-8371
Practice Address - Fax:540-416-4361
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-03
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator