Provider Demographics
NPI:1164891776
Name:RIVER RIDGE, LLC
Entity Type:Organization
Organization Name:RIVER RIDGE, LLC
Other - Org Name:RIVER RIDGE, LLC-BURNSVILLE OUTPATIENT
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:SAMMON
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LMFT, LADC
Authorized Official - Phone:952-564-3000
Mailing Address - Street 1:151 W BURNSVILLE PKWY
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-2524
Mailing Address - Country:US
Mailing Address - Phone:952-894-7722
Mailing Address - Fax:
Practice Address - Street 1:14750 LAC LAVON DR
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55306-6398
Practice Address - Country:US
Practice Address - Phone:952-894-7722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-24
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty