Basic Information
| Provider Information | |||||||||
| NPI: | 1649786047 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RIDDLE | ||||||||
| FirstName: | MITCHELL | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4631 WHITMAN LN SE STE D | ||||||||
| Address2: | |||||||||
| City: | LACEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985132250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603380181 | ||||||||
| FaxNumber: | 3603380257 | ||||||||
| Practice Location | |||||||||
| Address1: | 5905 N MAYFAIR ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992081127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094628010 | ||||||||
| FaxNumber: | 5094628011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2017 | ||||||||
| LastUpdateDate: | 12/20/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.