Healthcare Provider Details

I. General information

NPI: 1194213918
Provider Name (Legal Business Name): MATRIX BEHAVIORAL HEALTH PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2018
Last Update Date: 07/08/2021
Certification Date: 07/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 S BRADDOCK ST
WINCHESTER VA
22601-4090
US

IV. Provider business mailing address

12137 DOGWOOD LN
CULPEPER VA
22701-1352
US

V. Phone/Fax

Practice location:
  • Phone: 703-853-0959
  • Fax:
Mailing address:
  • Phone: 803-260-9897
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number525
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. BRENDA LEONA RIDGEWAY
Title or Position: CEO/CLINICAL PRACTITIONER
Credential: PHD, LSATP
Phone: 803-260-9897