Basic Information
| Provider Information | |||||||||
| NPI: | 1902155914 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RIDGLE | ||||||||
| FirstName: | NIA | ||||||||
| MiddleName: | LENISE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3525 SUMMER PARK DR APT 162 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958341744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9165293804 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3353 BRADSHAW RD | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958272607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9168544564 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2012 | ||||||||
| LastUpdateDate: | 09/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.