Provider Demographics
NPI:1790841153
Name:RIDENOUR, BRADLEY JOE (LPC)
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:JOE
Last Name:RIDENOUR
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 S ROSEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MONETT
Mailing Address - State:MO
Mailing Address - Zip Code:65708-1235
Mailing Address - Country:US
Mailing Address - Phone:417-235-0741
Mailing Address - Fax:
Practice Address - Street 1:509 S JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:MO
Practice Address - Zip Code:65605-2213
Practice Address - Country:US
Practice Address - Phone:417-678-0403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002010860101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health