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1619480712

NPI Code Detail

MEDICARE: AMANDA MARIE RIDGELEY

MEDICARE: AMANDA MARIE RIDGELEY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	6362007710	MI
2	171M00000X	Case Manager/Care Coordinator		OH
3	172V00000X	Community Health Worker		OH
4	106S00000X	Behavior Technician
5	103TC0700X	Clinical Psychologist	6301017265	MI

General Provider Information

NPI Number	:	1619480712
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA MARIE RIDGELEY

Provider Business Mailing Address
First Line	:	720 COLISEUM DR STE 92
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27106-5357
Country	:	US
Telephone Number	:	743-255-4568
Fax Number	:

Provider Business Practice Location Address
First Line	:	720 COLISEUM DR STE 92
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27106-5357
Country	:	US
Telephone Number	:	743-255-4568
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/10/2017
Last Update Date	:	10/18/2024

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Directions to “ AMANDA MARIE RIDGELEY ” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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