Provider Demographics
NPI:1891066031
Name:RIDDELL, TAYLOR LEIGH (COTA)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:LEIGH
Last Name:RIDDELL
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:LEIGH
Other - Last Name:RIDDELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:3600 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-2534
Mailing Address - Country:US
Mailing Address - Phone:817-377-3422
Mailing Address - Fax:
Practice Address - Street 1:3600 W 7TH ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-2534
Practice Address - Country:US
Practice Address - Phone:817-377-3422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-19
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX210895224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX456678OtherMEDICARE