1477250926 NPI number — SIERRA DAWN RIDLEY NONE-BEHAVIOR ASSIST

Table of content: SIERRA DAWN RIDLEY NONE-BEHAVIOR ASSIST (NPI 1477250926)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477250926 NPI number — SIERRA DAWN RIDLEY NONE-BEHAVIOR ASSIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RIDLEY
Provider First Name:
SIERRA
Provider Middle Name:
DAWN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NONE-BEHAVIOR ASSIST
Provider Gender Code:
F

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:
1477250926
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/14/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7108 S KANNER HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STUART
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34997-7462
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
855-832-6727
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4405 BASS MCHAN DR NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30721-6834
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-313-3862
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/14/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106S00000X , with the licence number:  BACB896657 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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