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General NPI Number Information
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NPI Number | 1205387990
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Entity Type | Individual
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Provider Name | KIRK REMON RIDDLE LICENSED PROFESSIONA
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Gender | Male
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Dates
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Enumeration Date | 10/18/2016
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Last Update Date | 10/18/2016
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Provider Practice Location Address
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Address Line | 1525 E. 53RD STREET, SUITE 425
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City | CHICAGO
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State | IL
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Zip | 60615
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Country | US
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Telephone | 773-819-5504
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Fax |
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Provider Business Mailing Address
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Address Line | 8627 S. WOOD STREET
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City | CHICAGO
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State | IL
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Zip | 60620
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Country | US
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Telephone | 904-502-3007
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 01YP2500X
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License Number State | IL
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