Basic Information
| Provider Information | |||||||||
| NPI: | 1972952547 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RIDDICK | ||||||||
| FirstName: | ALEX | ||||||||
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| Credential: | LCSW, LCAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 BRIGHTHURST DR UNIT 210 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276051282 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2528626050 | ||||||||
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| Practice Location | |||||||||
| Address1: | 877 E GANNON AVE STE 103 | ||||||||
| Address2: | |||||||||
| City: | ZEBULON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275979445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144962568 | ||||||||
| FaxNumber: | 9198291357 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2016 | ||||||||
| LastUpdateDate: | 11/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | P010437 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.