=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649786047
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MITCHELL LEE RIDDLE OT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2017
-----------------------------------------------------
Last Update Date | 05/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16528 E DESMET CT STE B2200
-----------------------------------------------------
City | SPOKANE VALLEY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99216-3522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-944-8920
-----------------------------------------------------
Fax | 509-462-8011
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 31001-4114
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91110-4114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OT60825215
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------