Healthcare Provider Details

I. General information

NPI: 1194300517
Provider Name (Legal Business Name): KENNETH RIDGEWAY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2021
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2221 S A ST STE 101
PERRIS CA
92570-9318
US

IV. Provider business mailing address

1254 SUNSET AVE
PERRIS CA
92571-3790
US

V. Phone/Fax

Practice location:
  • Phone: 951-940-4942
  • Fax:
Mailing address:
  • Phone: 951-448-9702
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number260090955
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: