Healthcare Provider Details

I. General information

NPI: 1710085105
Provider Name (Legal Business Name): ROBERT R IDDINGS PH. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 08/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1363 W 6TH ST
ERIE PA
16505-2559
US

IV. Provider business mailing address

529 VERMONT AVE
ERIE PA
16505-2337
US

V. Phone/Fax

Practice location:
  • Phone: 814-490-4740
  • Fax: 814-455-0754
Mailing address:
  • Phone: 814-490-4740
  • Fax: 814-455-0754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLP004193
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPS016657L
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS016657L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: