Healthcare Provider Details

I. General information

NPI: 1346301405
Provider Name (Legal Business Name): RONALD CLAYTON ELDRIDGE CSAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 N SAINT ASAPH ST
ALEXANDRIA VA
22314-1912
US

IV. Provider business mailing address

12208 PARKTON CT
FT WASHINGTON MD
20744-6130
US

V. Phone/Fax

Practice location:
  • Phone: 703-838-4455
  • Fax: 703-838-5970
Mailing address:
  • Phone: 703-838-4455
  • Fax: 703-838-5070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0710000855
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: