Provider Demographics
NPI:1467957332
Name:RIDGEWAY, BRENDA LEONA (PHD, LCAC)
Entity Type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:LEONA
Last Name:RIDGEWAY
Suffix:
Gender:F
Credentials:PHD, LCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 2 BOX 26A
Mailing Address - Street 2:
Mailing Address - City:HOOKER
Mailing Address - State:OK
Mailing Address - Zip Code:73945-9619
Mailing Address - Country:US
Mailing Address - Phone:803-260-9897
Mailing Address - Fax:
Practice Address - Street 1:504 N KANSAS AVE STE B
Practice Address - Street 2:
Practice Address - City:LIBERAL
Practice Address - State:KS
Practice Address - Zip Code:67901-3346
Practice Address - Country:US
Practice Address - Phone:620-604-5274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-24
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS525101YA0400X, 103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)