Provider Demographics
NPI:1457494650
Name:RIDGELEY, CONNIE L (LMHC)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:L
Last Name:RIDGELEY
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:L
Other - Last Name:DODGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3145 N PALM AIRE DR APT 201
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33069-3838
Mailing Address - Country:US
Mailing Address - Phone:954-552-5790
Mailing Address - Fax:
Practice Address - Street 1:3145 N PALM AIRE DR APT 201
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33069-3838
Practice Address - Country:US
Practice Address - Phone:954-552-5790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH8728101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL767849500Medicaid