Provider Demographics
NPI:1043986748
Name:RIDALL-VILLAGOMEZ, KIMBERLY LYNN (MED)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:LYNN
Last Name:RIDALL-VILLAGOMEZ
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:LYNN
Other - Last Name:RIDALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED
Mailing Address - Street 1:771 BROWNLEE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:GA
Mailing Address - Zip Code:30233-2413
Mailing Address - Country:US
Mailing Address - Phone:910-920-7357
Mailing Address - Fax:
Practice Address - Street 1:771 BROWNLEE RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:GA
Practice Address - Zip Code:30233-2413
Practice Address - Country:US
Practice Address - Phone:910-920-7357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-22
Last Update Date:2021-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool