Healthcare Provider Details

I. General information

NPI: 1740443860
Provider Name (Legal Business Name): GAGE RIDDOCH PSYD, ABPP, LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2008
Last Update Date: 11/28/2023
Certification Date: 11/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MEDDAC-BAVARIA CMR 411
APO AE
09112
US

IV. Provider business mailing address

MEDDAC-BAVARIA CMR 411
APO AE
09112
US

V. Phone/Fax

Practice location:
  • Phone: 145-901-8113
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPY00003860
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL6002
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY 00003860
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: