Healthcare Provider Details

I. General information

NPI: 1831079912
Provider Name (Legal Business Name): QUINCY RIDLEY BSW, MSW, LCSWA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2025
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5056 GRAIN ORCHARD RD
INDIAN TRAIL NC
28079-2315
US

IV. Provider business mailing address

5056 GRAIN ORCHARD RD
INDIAN TRAIL NC
28079
US

V. Phone/Fax

Practice location:
  • Phone: 253-209-9772
  • Fax:
Mailing address:
  • Phone: 253-209-9772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP020011
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: