Healthcare Provider Details

I. General information

NPI: 1104402155
Provider Name (Legal Business Name): MARISA SUE RIDLEY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2021
Last Update Date: 10/23/2023
Certification Date: 10/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7300 N PERIMETER RD
MALMSTROM AFB MT
59402-6701
US

IV. Provider business mailing address

820 IRONWOOD ST
GREAT FALLS MT
59405-7949
US

V. Phone/Fax

Practice location:
  • Phone: 406-731-3218
  • Fax:
Mailing address:
  • Phone: 903-821-7532
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number65254
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11903428-3507
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: