Provider Demographics
NPI:1114699048
Name:RIDGE, MICHAEL ALLISON (LCSW)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALLISON
Last Name:RIDGE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 W BROAD ST APT 317
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22046-3244
Mailing Address - Country:US
Mailing Address - Phone:703-966-9658
Mailing Address - Fax:
Practice Address - Street 1:10615 JUDICIAL DR STE 301
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-7501
Practice Address - Country:US
Practice Address - Phone:703-667-0752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-29
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040091751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0904009175OtherCOMMONWEALTH OF VIRGINIA DEPARTMENT OF HEALTH PROFESSIONS, BOARD OF SOCIAL WORK