Provider Demographics
NPI:1659948792
Name:RIDLEY, MARCELLA
Entity Type:Individual
Prefix:
First Name:MARCELLA
Middle Name:
Last Name:RIDLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELLIE
Other - Middle Name:
Other - Last Name:RIDLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 931142
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-1142
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4515 SPRUILL AVE
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29405-4764
Practice Address - Country:US
Practice Address - Phone:843-352-7049
Practice Address - Fax:615-815-1946
Is Sole Proprietor?:No
Enumeration Date:2021-06-08
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0-23-14490106E00000X
SCRBT-21-172389106S00000X
SC1-24-71216103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician