Provider Demographics
NPI:1922870716
Name:PRIDGEN, KADEEDRAH (LCMHCA)
Entity Type:Individual
Prefix:
First Name:KADEEDRAH
Middle Name:
Last Name:PRIDGEN
Suffix:
Gender:F
Credentials:LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6111 BULLTOWN RD
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:NC
Mailing Address - Zip Code:28551-7272
Mailing Address - Country:US
Mailing Address - Phone:404-915-9998
Mailing Address - Fax:
Practice Address - Street 1:6111 BULLTOWN RD
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:NC
Practice Address - Zip Code:28551-7272
Practice Address - Country:US
Practice Address - Phone:404-915-9998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-25
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-29382101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)