Provider Demographics
NPI:1053906412
Name:RIDDLE, JOHANNA
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:
Last Name:RIDDLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 RICHARDSON CORNER RD
Mailing Address - Street 2:
Mailing Address - City:CHARLTON
Mailing Address - State:MA
Mailing Address - Zip Code:01507-1428
Mailing Address - Country:US
Mailing Address - Phone:774-641-0134
Mailing Address - Fax:
Practice Address - Street 1:345A GREENWOOD ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01607-1753
Practice Address - Country:US
Practice Address - Phone:424-363-0389
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-07
Last Update Date:2021-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician