Provider Demographics
NPI:1053367078
Name:RIDDELL, GRACE CLAIRE (LICSW, LCSW)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:CLAIRE
Last Name:RIDDELL
Suffix:
Gender:F
Credentials:LICSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 CONNECTICUT AVENUE NW
Mailing Address - Street 2:SUITE 137
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20008
Mailing Address - Country:US
Mailing Address - Phone:301-942-3237
Mailing Address - Fax:301-942-2047
Practice Address - Street 1:3000 CONNECTICUT AVE NW
Practice Address - Street 2:SUITE 137
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20008-2509
Practice Address - Country:US
Practice Address - Phone:301-942-3237
Practice Address - Fax:301-942-2047
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC3013781041C0700X
MD055231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
674441Medicare ID - Type Unspecified
R24811Medicare UPIN
000B30M32Medicare ID - Type Unspecified