MEDICARE: DR. MICHAEL C. RIORDAN PSYD.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103G00000X	Clinical Neuropsychologist	PY 4565	FL
2	103TC0700X	Clinical Psychologist	PY 4565	FL
3	103TF0200X	Forensic Psychologist	PY 4565	FL

General Provider Information

NPI Number	:	1144258096
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL C. RIORDAN PSYD.

Provider Business Mailing Address
First Line	:	PO BOX 3757
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34948-3757
Country	:	US
Telephone Number	:	772-464-5555
Fax Number	:	772-468-8378

Provider Business Practice Location Address
First Line	:	2107 S 10TH ST
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34950-5318
Country	:	US
Telephone Number	:	772-464-5555
Fax Number	:	772-468-8378

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/29/2006
Last Update Date	:	10/23/2007

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