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General NPI Number Information
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NPI Number | 1861412371
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Entity Type | Organization
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Legal Business Name | JOHN B RIDGEWAY,LLC
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Dates
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Enumeration Date | 07/20/2006
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Last Update Date | 11/06/2007
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Provider Practice Location Address
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Address Line | G-4511 MILLER ROAD, 2ND FLOOR
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City | FLINT
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State | MI
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Zip | 48507
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Country | US
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Telephone | 810-720-0640
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Fax | 810-720-0640
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Provider Business Mailing Address
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Address Line | G-4511 MILLER ROAD, 2ND FLOOR
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City | FLINT
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State | MI
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Zip | 48507
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Country | US
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Telephone | 810-720-0640
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Fax | 810-720-0640
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Authorized Official
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Title or Position | SOLE OWNER
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Name | MR. JOHN BURNS RIDGEWAY
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Credential | MA,LLP,LSW,CAC-1,SAP
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Telephone | 810-720-0640
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 101948. CAC-1
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | SAP
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License Number State | MI
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Taxonomy #3
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 6801013086
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License Number State | MI
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Taxonomy #4
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 6301003780
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License Number State | MI
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