Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) | 246180 | KY |
NPI | 1003372905 |
---|---|
Provider Name | Mr. Andre Riddick SR. |
First Address | Lexington, KY 40508-2991 |
Second Address | Mount Sterling, KY 40353-1303 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/02/2019 |
Last Update Date | 15/02/2019 |