Provider Demographics
NPI:1801272208
Name:RIDDICK, PHILLIP (LCSW)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:RIDDICK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121B KELLER AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23504-3106
Mailing Address - Country:US
Mailing Address - Phone:757-679-2583
Mailing Address - Fax:
Practice Address - Street 1:733 THIMBLE SHOALS BLVD
Practice Address - Street 2:STE. 170
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-4260
Practice Address - Country:US
Practice Address - Phone:757-301-1314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-07
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040090461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical