Healthcare Provider Details

I. General information

NPI: 1326021205
Provider Name (Legal Business Name): CHRISTOPHER CHARLES RIDDICK LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 S DENTON TAP RD SUITE 270
COPPELL TX
75019-4098
US

IV. Provider business mailing address

580 S DENTON TAP RD SUITE 270
COPPELL TX
75019-4098
US

V. Phone/Fax

Practice location:
  • Phone: 972-393-1596
  • Fax: 972-304-0400
Mailing address:
  • Phone: 972-393-1596
  • Fax: 972-304-0400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number14255
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: