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General NPI Number Information
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NPI Number | 1790841153
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Entity Type | Individual
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Provider Name | BRADLEY JOE RIDENOUR LPC
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Gender | Male
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Dates
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Enumeration Date | 12/29/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 509 S JEFFERSON AVE
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City | AURORA
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State | MO
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Zip | 65605-2213
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Country | US
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Telephone | 417-678-0403
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Fax |
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Provider Business Mailing Address
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Address Line | 906 S ROSEWOOD DR
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City | MONETT
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State | MO
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Zip | 65708-1235
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Country | US
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Telephone | 417-235-0741
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 2002010860
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License Number State | MO
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