Provider Demographics
NPI:1891777264
Name:RIDLEY, ROBERT MYRON (LPC)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:MYRON
Last Name:RIDLEY
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 1:441 E BROAD ST
Mailing Address - Street 2:SUITE H
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-3389
Mailing Address - Country:US
Mailing Address - Phone:931-544-1096
Mailing Address - Fax:931-451-3774
Practice Address - Street 1:441 E BROAD ST
Practice Address - Street 2:SUITE H
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-3389
Practice Address - Country:US
Practice Address - Phone:931-544-1096
Practice Address - Fax:931-451-3774
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLPC0000001599101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5441348Medicaid