Provider Demographics
NPI:1144258096
Name:RIORDAN, MICHAEL C (PSYD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:C
Last Name:RIORDAN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3757
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34948-3757
Mailing Address - Country:US
Mailing Address - Phone:772-464-5555
Mailing Address - Fax:772-468-8378
Practice Address - Street 1:2107 S 10TH ST
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-5318
Practice Address - Country:US
Practice Address - Phone:772-464-5555
Practice Address - Fax:772-468-8378
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 4565103G00000X, 103TC0700X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL73818AMedicare ID - Type UnspecifiedLICENSED PSYCHOLOGIST