MEDICARE: EMILY ELENA RIDENOUR LMSW

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	104100000X	Social Worker	3783	CT

General Provider Information

NPI Number	:	1902541907
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMILY ELENA RIDENOUR LMSW

Provider Business Mailing Address
First Line	:	26 OAKENGATES
Second Line	:
City	:	AVON
State	:	CT
Zip	:	06001-2640
Country	:	US
Telephone Number	:	860-829-7344
Fax Number	:

Provider Business Practice Location Address
First Line	:	26 OAKENGATES
Second Line	:
City	:	AVON
State	:	CT
Zip	:	06001-2640
Country	:	US
Telephone Number	:	860-829-7344
Fax Number	:

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

Provider Enumeration Date	:	05/03/2022
Last Update Date	:	05/03/2022

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