Provider Demographics
NPI:1366004541
Name:BENNETT RIDGWAY, DEANNA LAVONNE
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:LAVONNE
Last Name:BENNETT RIDGWAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DEANNA
Other - Middle Name:LAVONNE
Other - Last Name:RIDGWAY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 341
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95812-0341
Mailing Address - Country:US
Mailing Address - Phone:916-572-4163
Mailing Address - Fax:
Practice Address - Street 1:2750 SUTTERVILLE RD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95820-1024
Practice Address - Country:US
Practice Address - Phone:916-572-4163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-08
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1070671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical