Provider Demographics
NPI:1962266676
Name:RIDDICK, BRANDON PATRICK (LCMHC-A)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:PATRICK
Last Name:RIDDICK
Suffix:
Gender:M
Credentials:LCMHC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 PINE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH MILLS
Mailing Address - State:NC
Mailing Address - Zip Code:27976-9426
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 W CHURCH ST
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-4510
Practice Address - Country:US
Practice Address - Phone:336-457-4899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-13
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA19701101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health