Provider Demographics
NPI:1447474366
Name:RIDLEY, THERESA MARLENE (LCSWC)
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:MARLENE
Last Name:RIDLEY
Suffix:
Gender:F
Credentials:LCSWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 GWYNNWEST ROAD
Mailing Address - Street 2:
Mailing Address - City:REISERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21136
Mailing Address - Country:US
Mailing Address - Phone:443-722-4055
Mailing Address - Fax:
Practice Address - Street 1:5602 BALTIMORE NATIONAL PIKE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21228
Practice Address - Country:US
Practice Address - Phone:443-722-4055
Practice Address - Fax:410-744-3326
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDL126501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical