1477082857 NPI number — SARA RIDLEY COUNSELING PRACTICE, LLC

Table of content: (NPI 1477082857)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477082857 NPI number — SARA RIDLEY COUNSELING PRACTICE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SARA RIDLEY COUNSELING PRACTICE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477082857
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1315 GRANGER AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKEWOOD
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44107-2232
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-941-3285
Provider Business Mailing Address Fax Number:
440-815-2189

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1315 GRANGER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKEWOOD
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44107-2232
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-941-3285
Provider Business Practice Location Address Fax Number:
440-815-2189
Provider Enumeration Date:
06/08/2017

Additional Information

Authorized Official

Authorized Official Last Name:
RIDLEY
Authorized Official First Name:
SARA
Authorized Official Middle Name:
JOYCE
Authorized Official Title or Position:
OWER/CLINICAL SOCIAL WORKER
Authorized Official Telephone Number:
440-241-6054

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X , with the licence number:  I1000364 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0099016 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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