Provider Demographics
NPI:1588221808
Name:KRIDEL, MATTHEW MICHAEL (PHD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:MICHAEL
Last Name:KRIDEL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:997 SAINT SEBASTIAN WAY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30912-2613
Mailing Address - Country:US
Mailing Address - Phone:706-721-6597
Mailing Address - Fax:
Practice Address - Street 1:997 SAINT SEBASTIAN WAY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-2613
Practice Address - Country:US
Practice Address - Phone:706-721-6719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-22
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GAPSY004537103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program