Provider Demographics
NPI:1144727512
Name:RIDDELL, BLAKE ALEXANDER (PSYD)
Entity type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:ALEXANDER
Last Name:RIDDELL
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 1:304 FOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-3816
Mailing Address - Country:US
Mailing Address - Phone:817-808-8053
Mailing Address - Fax:
Practice Address - Street 1:600 SUNLAND PARK DR.
Practice Address - Street 2:BLDG. 6, SUITE 100
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-7991
Practice Address - Country:US
Practice Address - Phone:915-584-3636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-11
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37783103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical