Healthcare Provider Details

I. General information

NPI: 1972952547
Provider Name (Legal Business Name): ALEX RIDDICK LCSW, LCAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2016
Last Update Date: 11/10/2020
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

877 E GANNON AVE STE 103
ZEBULON NC
27597-9445
US

IV. Provider business mailing address

1000 BRIGHTHURST DR UNIT 210
RALEIGH NC
27605-1282
US

V. Phone/Fax

Practice location:
  • Phone: 314-496-2568
  • Fax: 919-829-1357
Mailing address:
  • Phone: 252-862-6050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP010437
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: